Occupational Therapy Notes

What can OT do for a person with a hip fracture or hip replacement? More info in the full post.
Note: this post was written several years ago but still holds true. Just be aware that surgeries and protocols are changing with time and each surgeon will have their own specifics they want followed. I worked at a facility where the surgeons preferred a 2-incision "mini" replacement that carried no precautions, and several who debate whether to use an anterior or posterior approach. Just be up to date on what is preferred by your medical team.


Often, if the hip breaks near the joint's socket, the orthopedic surgeon will perform a total hip replacement (THR). This is also a common elective procedure for individuals w/ degenerative joint disease (DJD). There have been several advances in the operation, and there are new techniques that are less invasive and don't carry hip precautions. If for some strange reason you were pushed into a room with a patient you had no information on, and wanted to know whether this patient had a THR w/ precautions or an ORIF/pinning w/o precautions, the presence of a brace that extends from ankle to groin or a giant triangular pillow attached between the legs is the flashing sign that says "YES, I HAVE PRECAUTIONS." Don't count on the pt. to remember, as you may not have done a full cognitive eval yet, and it may have slipped even a very intact person's mind after the anesthesia.

For the sake of this example, we'll assume that our subject "M" has a THR w/ the standard precautions (no hip flexion past 90*, no crossing midline w/ operated leg, no internal hip rotation) and the fourth (no active abduction) which is used depending on the location of the fracture and the surgeon. There will also be a note about weight bearing status. Often, a person electing to have this surgery at a younger age will be allowed to weight bear as tolerated (WBAT). If there is more concern over the stability of the joint or bones, the surgeon will want less weight on that leg. We'll assume that "M" is partial weight bearing, which means that only 50% of her weight on the operated leg. (This saves us from having to explain toe-touch WB with the uncomfortable metaphor of not crushing an egg under your foot; and from non-WB which means that you have to hop. I have done the hopping w/ several... most recently an 89 y.o. female, and progress was slow)

We'll assume that in the OT evaluation, the therapist developed an occupational profile of "M", highlighting her concerns and priorities. We won't go into that in-depth in this post, as I actually want to finish it at some point. But, from my 'chart review,' I see that "M" is an educated woman who was respected at her job and has family support. The report states that she lives in a high-rise, which is good because it probably has elevators, but could be bad if they have rules about adaptations to apartments for safety. She also has vision difficulties, which could complicate ADL retraining.

ADL retraining, or relearning how to do the basic activities of bathing, dressing, toileting, transferring, etc, will be a large part of an OT's treatment for "M." Learning and understanding hip precautions is also a major task- non-medical personnel are not likely to instantly understand hip flexion, adduction, abduction, so this is a key for the therapist to rephrase, review, and demonstrate precautions so that the patient does not forget them and does not pop their hip out. Standard hip precautions often have to be followed for 3 months, so it needs to become second nature. (I once had a gentleman w/ dementia in his 80's that could not remember and understand these. He liked to draw, so I taped paper up on the wall and had him stand and draw cartoons of people obeying hip precautions) Here's some quick ways to simplify the precautions while covering some of the contingency situations:

• No hip flexion beyond 90*: Don't bend over! Don't try to get anything off the floor without a reacher! Don't lean forward when standing up from a chair. Use the adaptive equipment for dressing. (As a therapist, you can also help by modifying the hospital bed so that the legs don't raise. Often a little button on the foot of the bed or on the outside of a rail)
• No crossing over midline: Don't cross your legs! Use the wedge or pillows between your legs in bed. Avoid sleeping on your side.
• No hip internal rotation: Keep your toes pointed up in bed, don't let them turn toward each other. Don't pivot on the operated leg.

How is "M" going to get bathed and dressed independently when she can't bend over? Adaptive Equipment/Devices. A "hip kit" is often recommended, but there are cheaper alternatives to the medical supply stores. Reachers and long sponges can be found at many discount and pharmacy stores. Long handled shoe horns are found at my local Dollar Tree. (I have a handout on how to make dressing sticks, long sponges, and sock aids from household items, but I can't lay hands on it. Will link to it later.) At any rate, an OT will work w/ "M" to help her develop new patterns and procedures for doing her daily tasks w/ devices as needed.

Transfers are often looked upon as "PT territory," but an OT can't expect to work without being comfortable helping people relearning safe transfers. This includes bed to chair, as well as into the tub or shower and to the toilet. Though the "comfort height" toilets are gaining ground, most people (and much of my hospital) has the standard 15" commode. This will not be workable for most individuals w/THR. There are risers for toilet seats, but I have always wondered about their sturdiness. I recommend getting a bedside commode / 3 in 1 toilet, throwing out the catcher/hat/pot, and putting it directly over the commode. In the tub or shower, I always recommend grab bars, and then experiment with different seats to see what works best for the patient. School-based OTs work to get their kids in the least-restrictive environment, I look for the least expansive tub chair that offers the patient the level of safety they need. I have had 1 person w/ THR demonstrate a safe step-in transfer to a tub, but most people will need some sort of seat to swivel into the tub. This is not natural to people, and takes practice.

As "M" progresses through the continuum of care from acute hospital, to skilled nursing, to home health (more likely than outpatient in her case), she will continue to work on more advanced skills that she had previously engaged in, such as cooking, car transfers, showering, etc, which OTs call IADLs. Hopefully someone will be able to visit her home as she gets near to discharge so that they can advise on home recommendations. That includes placement of grab bars, moving furniture, adaptations for low vision- anything to make "M" safer and more independent.

Happy Blogiversary to me! I've spent a fair amount of time the past five years working with geriatric patients and adult phys/dys in general. Here are some awesome tools that will augment your outpatient, SNF, ALF, inpatient rehab, or hospital based practice!


The great folks at Maddak have been very generous in providing many items for this giveaway. I have always liked Maddak because they provide a lot of unique tools that are very useful and they really respect the therapy professionals that use their tools. I love the awards they give out at the AOTA annual conference for therapist and student inventions that fill a new need, and now they have started a special "OT Circle" for therapists to provide feedback on their products.

A hip kit is one of the essentially useful items that Maddak has provided for the giveaway. No matter where you work, there's always the day that you run out of reachers. The kit contains a reacher, sock aid, shoe horn, and long handled sponge. Also included is one of my favorite items- a leg lifter! So useful especially in those days immediately following a surgery. I've found that a leg lifter can also be very helpful in performing safe tub transfers when leg mobility is still limited.

Two more super useful items from Maddak are included in this package. A Tenura jar opener is better shaped than the typical flat openers and specially shaped for bottles and jars. I have difficulty opening items and know from experience these are beyond helpful. A pack of tubing to build up handles, pens, and utensils is also a great tool in the phys/dys world for so many uses.

The Pencil Grip company makes more than just grips, but they have included jumbo grips for our giveaway to assist those with arthritis. Their standard grip is my favorite for kiddos (and myself) and the jumbo version takes those teeny tiny hard to grip pens and makes them into comfortable arthritis-friendly writing tools.

My favorite car transfer tool is also part of the giveaway. The Handybar has been such a great help to my grandmother for getting in and out of the car. This tool is compatible in any car and provides a stable bar to push from and balance on while trying to get in and out of the car. It's also compact enough that it easily fits in a purse or the door console. This is such a great tool, and I love promoting mobility throughout the lifespan.

In the "intangibles" file is a great gift from Tactus Therapy. They will be donating a free download of their Spaced Retrieval TherAppy app, a great tool for therapists working in cognition. I think this would be really relevant to therapists in community based settings with high level clients, but their site also says it can be used with lower level clients. This can be used on any iOS device, I'm anxiously awaiting their android versions.

From my collection of OT stuff, I have included a faucet nozzle light. This light is supposed to change the color of the water whether it is hot or cold and I thought would be very helpful for clients with diabetes or other sensation impairments. I haven't been able to try it out but hope that it works as advertised! Also included is a Twist 'n Write pencil, what we called a rocketship pencil in the school system. This is another item that is very arthritis-friendly and can be useful even if you have limited finger control.

Last, but certainly not least, remember that AOTA is always your best resource no matter your practice area. They have sent items to promote OT in your clinic, including a T-shirt, brand posters, and pens. For your everyday life, they've include a great tote bag and umbrella that I'm sure will have great usefulness no matter your job site.

WOOOOOO! that's our geriatric tool giveaway! If you're a practitioner in this area, enter now by leaving a comment below. Comments must be received before 11:59pm EST on January 31. Good Luck!

I normally don't do this. Even with people I speak with in person, I don't get very political. Partly due to the effects of being a blue dot in a red state, partly out of actual politeness and avoiding arguments, and partly because I don't think that most political discourse has an effect on how people actually vote. But as should be obvious from the title and the disclaimer thus far, I'm going to go there today. You have been warned. (as always, I'm sure that my employers -such as they are- and state associations that I am a member of have no voice in what I write, and the views are purely my own)

My father is an economist/history teacher and political discussions were the norm in our household from a young age forward. I now spend a good deal of time interfacing with our state lobbyist regarding how we can best protect and promote OT in my role as VP of Advocacy. I am a registered Democrat, but would more accurately describe myself as a political cynic. I think yard signs should be banned for anyone running for a higher office than the state legislature. I think that the debates should be abolished since they only serve as moments to spit out talking points, cherry picked statistics, and are altogether worthless until you see the Fact-Check. I get super irritated watching both candidates move closer to the center as election day nears and simultaneously knowing that a third-party candidate has no chance at all in going far enough to keep the other two honest. Don't even get me started on the rights of a SuperPAC.

One of my biggest responsibilities from a hospital standpoint is providing discharge recommendations. Hospital stays are notoriously short and it is a priority of the case management staff and doctors to determine discharge location, for which they recruit OTs and PTs to assist. But determining discharge readiness and placement is more of an art than a science, no flow chart can be easily developed to guide a novice through the process. So here are 3 case examples of similar patients and situations, whom I saw on the same day, and my rationale for their discharge locations.

All three of the individuals were over 80 years old, with moderate dementia. They were all admitted with altered mental status caused by pneumonia and concurrent urinary tract infections. They were all living with family members prior to admission, who have each made a goal to keep the individual at home as long as possible. They are each oriented only to person at this time, but recognize their family members who were at bedside. Each person required max assist for bed-chair transfer and max assist for ADLs during OT eval.

Patient “Alan” lives with his also elderly brother. They have been living together almost their entire lives, and until about 5 years ago were very active in several community activities. I think it is fair to say that they are brothers and also best friends. Alan has been declining in recent years however. He is normally able to walk at home but is very unsteady, requires a lot of assist on the steps to the upper floor, and has had multiple falls at home endangering him and his brother. Alan's brother tearfully states that he is unable to help him after falling, which is becoming more frequent. Alan has not been able to leave the house for some time, and his brother is only able to go out for short trips to the grocery store, which he recognizes still poses a safety risk by leaving Alan alone. They have a 2 story home, good DME setup, and some rare support from friends (no remaining family).

Patient “Betty” is a very pleasant woman, always smiling, happy and friendly. Her daughter is a retired pediatric nurse, but is frustrated with herself for not knowing more about geriatric care. She noticed a cough developing earlier in the week but did not expect that illness would cause such a drastic change in her mother's personality and abilities. Normally Betty is able to walk w/o device and perform ADLs with supervision. However, Betty is very afraid of falling in the hospital environment, actually fighting the transfer, and requires max assist of 2 for chair to bed. She is still able to follow 1 step commands as long as they are not about transfers. Betty's daughter is well educated on devices, but has a bad back and cannot lift >10 pounds. Per pt's daughter, Betty did well in rehab previously after a hip replacement.

Patient “Carol” is lethargic and minimally responsive during the evaluation. She responds best to her daughter, and will follow 1 step commands from her. She has severe retropulsion in sitting. I could not transfer her, but her daughter was able to in a less than fully safe method. Daughter reports that there are multiple family members that live in the home with Carol, and others that assist in rotating care duties. They have good DME setup at home and 24 hour assist with various caregivers. Carol clearly responds best to her family members over the staff at the hospital.

Who gets to go where? There are few hard and fast rules in discharge planning. Because OT is committed to being client and family-centered (and because care for a person with moderate dementia requires a high level of commitment from the family), discussions regarding each option were provided to the families of the patients. These are the decisions we made together, though it is certainly possible that other therapists or case managers may have tried to elicit a different response.

Alan was recommended for a trial of inpatient rehabilitation at a subacute level to attempt to progress in ADLs and transfers. The plan was to select a facility that also provides long term care, as Alan's brother could no longer care for him at home. Special consideration was given to make this place close to their home so that Alan's brother could make frequent visits.

Betty was recommended for inpatient rehab at a subacute level at a facility she had been to previously. Betty's daughter would not be able to care for her currently, but was open to the idea of family training and purchase of lifting devices if needed to allow for her to return home after rehab. She also had a good connection with home therapists as well.

Carol was recommended to return home with home health therapy to address safety in transfers and additional adaptive equipment assessment for best safety at home for her and the family. She was unlikely to fare well in any facility cognitively or with physical progress. The family was ready to continue 24 hour assist and try whatever was necessary to provide for Carol.

Discharge planning is not always easy. Therapists, MDs, case managers and the family do not always reach agreement. But this was a situation where even though there were difficult decisions, each family unit got what was best for them, I think.

Any medical professional can tell you the hardest patients are the ones you're related to. Once you express interest in a degree, the health questions start coming in from all sides. I remember using my special tests book to r/o fracture after my brother punched a wall, digging through an orthopedic text to find the painful ROM arc of my mom's shoulder over the phone, and trying to diagnose a no-longer-present-but-still-bothersome-that-it-had-ever-appeared nodule for my dad- incredulous that this didn't involve a trip to the doctor. But there are limits to what anyone can do, especially from far away.

My dad had a heart attack after I finished my final OT fieldwork. I had several weeks that I was able to spend at home while he recovered. I don't recall doing much during that time except for just trying to keep a close watch on the recovery process, driving him to appts, and encouraging a gradual return to activity. I do remember questioning the MD about the quality of the hospital's cardiac rehab- I didn't want him doing dowel exercises to 90* and 20 mins UBE only- but they had a very good program able to help him return to playing football, teaching full time, etc.

My mom had an injury lately that exacerbated chronic back pain and forced a laminectomy. While I could answer some questions about spinal precautions, home adaptations, I couldn't help her with the insurance issues or prognostic questions like when she could go back to work. It was very hard for me to to counsel her by phone after her surgery despite the fact that I do that for non-relatives everyday.

But the most difficult has been my grandmother-in-law. I can't remember whether it was before or after the wedding that she asked her MD about Aricept because she felt she had memory problems. She had self-diagnosed Alzheimer's Disease (AD) correctly, unfortunately. Our visits were limited due to time and travel constraints, and initially she appeared to have only mild deficits. However, when the disease began to progress, I felt it moved quickly. Environmental modifications went from un-needed to un-beneficial quickly. We made some changes later, like raising the table legs so a wheelchair could fit underneath and relaying ramp specifications for her son to install. The home health agency actually responsible for her care got her a toilet seat with arms and a shower chair. I sent lots of activities and descriptions of how to grade tasks for her caregivers, but they were often too strapped for time to engage.

I got her a bright flowered walker bag as soon as she required a mobility device. However, she never could master the walker usage, and would lean backwards precariously while someone held the walker in front of her- very frightening. It is strange to transfer a family member. Sometimes I tell my patients that OT is "up close and personal" because of the lack of distance required for some activities. Anyway, despite initially being regarded as 'the expert' her caregivers and family that were there everyday were much more effective at her transfers than I was, even if I had to bite my tongue as they were less safe.

I had multiple discussions with my father-in-law about her ongoing need for care- pushing for 24 hour daily caregivers to relieve family and be safest. When her MD pushed for outpatient PT (WHY?!), I tried to relay that home health therapy was invented for the homebound and that bumping her in a wheelchair down a flight of stairs constituted excessive burden. We discussed that PT was not a cure all and that ambulation was getting unrealistic (despite what the doctor thought), but they pushed ahead. It was still sad for me when I heard she was d/c from PT due to plateauing, though I knew it was coming.

From there, the decline moved rapidly. She was already unable to hold a phone conversation, but became unable to stay awake for any activity in front of her. She had a few back-to-back hospitalizations and was sent home on hospice. A few short weeks later, one of the most loving and vibrant individuals I have ever known succumbed to one of the worst diseases of our time. Even though this outcome was expected and in fact certain, I still felt that I had failed along the way. I hadn't been able to adapt the walker to make it easier to use, conduct training with the caregivers, or give her a robust home program so that she could continue to participate. I can't even say that I did my best, as usually I had forgotten planned efforts- like sending her one of my violets. And I felt like I had failed the sweet and loving woman who gladly accepted me into the family.

My best efforts overall were probably with the rest of the family. I tried to encourage my stressed and overworked father-in-law to take care of his health and take time for himself, educate him on resources that were available in the community. I tried to address the frustration of my mother-in-law and explain behaviors that were related to the disease process and no longer under grandma's control. I tried to add perspective in general since the person we had loved was already gone due to AD. But I often felt more like an outside intruder than anything. Her daily caregivers, who had received some minimal education on working with the elderly, were able to handle the entire family's needs very well. Knowing that she was comfortable with "the girls" and the hospice workers is of great comfort and another testament that you should never consider yourself 'above' anyone, they have much to teach you and much that they are capable of beyond you.

I know that failure is a strong word, but I have always been a tough critic of my work. And in this case, where I know that I could've done better and that she deserved better, the sting is especially sharp. It's hard to be the therapist in the family and walk the line between personal and professional. It's hard to do all that should be done and still maintain roles. This is a difficult topic for me since I know the situation will only increase in frequency as the years go by. The health stability of the family is always tenuous, and I just hope each day that my expertise won't be needed.

As I have written before, Energy Conservation is a topic that I really enjoy and love to educate about. It's close to my mind often, since I love for tasks to be efficient and simplified. In this post, I want to discuss energy conservation tips applicable to the summer months and also to vacations. Though technically the first day of summer here was a couple of weeks ago, it's been in the high 80s and 90s for what feels like several months. Energy conservation is especially important in the summer months because for many folks who need to think about conserving energy, life gets harder in the heat. Harder to breathe and easier to fatigue are typical signs of the summer, and especially among those with cardiac and respiratory diseases and also the well elderly (If you are having these symptoms in summer or anytime, talk to your doctor!). That doesn't mean that life has to take a backseat during the summer months- just that conserving energy should come into play so you can enjoy and participate in all desired occupations.

Here are some tips:

• --Minimize time in the heat- try to be outdoors in the mornings and evenings, when it's cooler, and stay out of the sun and hottest part of the day when you can
  
• --Don't live on grueling pace in vacation spots- So many people take a trip somewhere exciting (such as Disneyworld) and then run themselves to death during the trip. Don't be afraid to take breaks and naps, you'll enjoy whatever trip you're on more if you're not run down. Also make sure to take some seated breaks in the shade during your outdoor adventures.
  
• --Take stretch breaks while traveling- Try to avoid driving for overly long stretches. Take a break every hour or 2 to keep yourself fresh and cramp-free.
  
• --Rotate driving- in the same vein, try to rotate the driving responsibilities so that no one person is worn out from the stress
  
• --Plan small, close trips- shorter trips can be less stress to plan and easier on the family
  
• --Go to places that are air conditioned- trips to museums and movie theaters can be easier to tolerate in the heat.
  
• --Get your exercise in the morning or evening- summer isn't an excuse to stop exercising, but try to do it in the cooler times of the day
  
• --Use a scooter at parks- if you're planning a big trip at an outdoor park, consider using a scooter or transport chair to save energy. Make sure you spend time in the shade as well
  
• --Use a backpack (well adjusted) or rolling cooler to transport water and snacks
  
• --Plan day trips for times when you have the most energy- run your errands and take your trips at the time of day that you have the most energy. For many people, this is the morning.
  
• --Nap after pool time- swimming always seems to wear me out extra, so I just allot time afterwards to take a nap
  
• --Consider making smaller meals that are simpler and have less to prepare- saves you energy and prevents any extra heat from accumulating in the house
  
• --Know your limits, and how to cool down- recognize what you need to do after activity to cool down. Sometimes, a seated rest break is insufficient, and you may need to drink or coat yourself with water, or lay down in a cool room. Lifehacker ran a piece on using your pulse points to assist in quick cooling.
  

What are some other tips you have to get the most out of summer while conserving energy?

This is my grandma, showing off the stretchy ring BLING she got for Christmas. She's always had an extensive jewelry collection, but in recent years her arthritis has made it too painful to wear her rings and too difficult to operate some clasps. Read on for some of the options for people who love their jewelry and hate their arthritis.

Stretchy rings/bracelets (Potpourri) - these rings have made their way into my grandma's regular rotation. There's matching bracelets for some and they slip on easily. (We got her the pearls and the ones with the single gem in the bottom right, not the crazy ones made of sticks) The ones from Potpourri are fairly inexpensive, I have seen similar ones in specialty stores MUCH more expensive so do some comparison shopping.

Magnetic clasp converters (shopping search) - I saw these on TV ads. They look like a person with arthritis might need assist with initial setup but then they should be independent to doff/don. I haven't personally tried them, so I can't speak to the strength of the magnets, but they're probably not strong enough to hold up heavy jewels like pearls.

Wire chokers/bracelets - These are pretty common, if you can convince an adult to shop with the preteens to get jewelry. Just look for the necklaces without clasps in U shape.

Bracelet fastener (bracelet buddy) - I was intrigued by this device when it first came out, but it may be too complicated as adaptive equipment now that other stuff has come out.

Took a bit of an OT break with a vacay to Las Vegas and reading some novels instead of OT stuff pretty much since Thanksgiving. Now I'm back and ready to play! Been working on a few entries off and on, but this is mostly unstructured.

My NBCOT was due to be renewed this year, which caused a minor panic attack the other day. Not that I've been slacking on licensure or anything, I've been going to conferences, but there was a wrinkle I didn't anticipate. I graduated in May '07, but didn't test until Aug '07. My original state license did not require first year graduates to submit continuing ed to be recertified. And unlike the first 2 years of my OT schooling, I didn't pick up any CEUs in my final year due to silly things like fieldwork, graduation, getting married, etc. Somewhere in the back of my head, I had this idea that I wouldn't renew NBCOT until NEXT year, or at least until Aug of this year. WRONG-O. All 36 hours needed to be complete as of 12/31/09. I was tweaking out quite a bit, until I reread the guidelines for all activities that count (can't link it since NBCOT is rather difficult to navigate, but it should be readily accessible if you're due to renew) which includes staff inservices, fieldwork student supervision, and reading journal or textbook articles. In the past 2 years, I have actually read 40 textbook chapters afresh and over 20 journal articles. I had to go back and count though, because I was stupid and hadn't been writing it down. So major props to Your Therapy Source, HeathSkills, and ABC Therapeutics, who all either cite their resources for posts or write specifically about certain articles, because at least they can keep track of what they've read. I hope to start doing that. Usually the journals just pile up beside my laptop though, they don't actually make it into posts.

Switched some days around at work, I am on 11 of the next 12. ugh. but I am starting to get into a groove on the medicine floor. I think the biggest challenge is just striking a balance between evals and priority follow ups. We don't have as many people going to acute rehab as on the other floors, so the regulation for most recent note is a little more lax. Few happy stories on the medicine floor... you don't get to watch people making dramatic recoveries like on the other floors, there are a lot of repeat admissions and people just getting generally sicker.

Had a couple of people competing for saddest story before I left for vacation. Lady A has cancer and has been having seriously miserable orthostatic hypotension. She has been existing by running to her destinations in hope to make it there before passing out, and was admitted s/p fall on one occasion where that didn't work out superbly. I believe we had a standing BP in the 60/40 range (NOT GOOD). When I was getting her history, it was very sad, because she said she knew she wasn't going to live through her current chemo regimen. However, she at least had plenty to live for. "I want to make it to July," she said. She had relatives graduating college and high school, another getting married, and a major milestone anniversary coming up with her husband. I almost cried. I am a big believer in the power of things to live for though, so I really hope she makes it.

Lady B was a sad case as well, same day. She was majorly depressed, and in some cases very rightfully so. From her description, it sounded like her husband had dementia and she had been very hurt by him commenting about how he didn't love her anymore and some of the barriers that the healthcare machine had placed between them. However she also had some episodes of paranoia and visual hallucinations, as well as frequent falls (her admitting dx). I was thoroughly confused. 80 years old is pretty late in life for a schizophrenic break. An experienced PT pointed out that sometimes Parkinson's Disease presents with psychosis, and that seemed to make things make more sense. Sometimes I wonder if I will just know stuff like that off the bat.

Ms N was bumming me out the other day as well. I saw her before for a home safety evaluation, which was very unstructured and not super fun as her normal pleasantly confused affect turned into nasty and aggressive when asked to take part. She is normally very nice, saying hello to all who pass her room and wandering the hallways with supervision. But the other day she was walking and crying her eyes out, calling for her mother, totally inconsolable for the duration of the day. I was very sad for her, and for a lot of people in general. Dementia is such a harrowing disease.

Even as an OT I often feel helpless in my own family, where a grandmother is in the mod-severe stages of Alzheimer's Disease. I have tried to make suggestions where I can, but I'm not there 24 hours a day and really can tell that everyone is getting emotionally and physically worn out just trying to do their best. We're also beyond the point of many environmental adaptations, which is where my strength is. I think that it's overall better for her quality of life and her husband's to have them in their home, but it's hard. Right now, the major issue is her walking. She didn't learn to use a walker before AD, and has never been able to really grasp it since. Right now they are walking with handheld assist but she leans backward A LOT. It is scary to watch. Scary enough that when I was there I transferred her to a wheelchair to move her 15' to the dining room. Even then she almost fell out of the dining room chair that didn't have arms. I don't really know what to suggest to help with this gait problem. We did go out and get bed risers and cut them down to fit the dining room table so the wheelchair arms will fit under the table, and make eating a little safer. I had to leave strict instructions though that wheelchair was for meals and to the porch ONLY, she was not to sit in it all day. Need to check in and see how this is going. Any suggestions welcome.

Back to a few less depressing random notes-
I was reading an article about a guy who has motivating himself to lose weight by pledge drives and donating all the money to cancer research. Great idea I think, because sometimes it is not enough to be doing something "for your health." Saying "it's good for you" does not always make you do the right thing, but if you have that extra motivator of someone counting on you, it can make it worth it. In the comments section, a poster (#47) was asking for weight loss advice and I am sure she would take your suggestions:

Weight loss experts, I NEED YOUR HELP!! I'm the elder sister of a developmentally disabled adult (36) who is at least 200+ lbs overweight. Given his relatively small stature, we're talking about a dangerous level of obesity. My question is this: does anyone have any recommendations for programs, procedures, etc. for those with cognitive disabilities? Since his impairment (a mild form of Down's) is related to both motor and impulse control the usual advise of "eat less and exercise more" doesn't work. His impairment is sufficiently mild that he would be discomforted by placement in a program with very disabled individuals. His doctors have warned us that a stroke or heart attack are not unheard of in his age group and, obviously, further impairment would prevent him from even enjoying the limited amount of independence he now has. Any help would be very very welcome.

Comments do require an extremely short registration. My initial thought was that there are exercise videos for people with Prader Willi Syndrome, but these are marketed mostly for children and teens.

That article led me to a blog I hadn't seen before discussing Fat Prejudice in Health Care. These are stories that people have emailed in, so there is a lot of raw language, you probably shouldn't read it at work. However, it would be good to talk about at work, because I know there is a lot of prejudice in the OT/PT world. (Here is a PT related story) As a professional who is expected to transfer any patient, it can be intimidating to walk into some rooms. Yet I will say that the gastric bypass patients we see are among the most mobile of all referrals, usually welcome a little adaptive equipment to restore some independence, and are often good to go after 1-2 sessions. Obviously as OTs we need to make sure that we're treating all clients with dignity and respect. It's still good to challenge your thinking about your practice and make sure that's happening.

Sometimes I think these clock drawings are revealing, sometimes just plain confusing.


This was my first experience with the Montreal Cognitive Assessment, which is becoming my preferred pencil/paper tool. However, it does start off with alternating trailmaking and has a 5 words after 5 minutes recall section, both of which are rather difficult for many people. But it's free and more discriminating than the Mini-Mental. The MDs wanted a KELS on this lady to determine if she could go home or not, but our manual was missing so I went with a basic functional eval and the MOCA. (could have stopped after the functional eval... if you can't get your pants on, you can't go home) This lady got 2/3 points for the clock since she does have numbers and a full circle, but again has just drawn a location on the rim of the clock for the time.


Finally, my most recent, which was another attempt at the MOCA but the woman almost swung at me when I brought out the paper. So we administered the test by walking around the unit and intermittently asking questions. I find it interesting that the numbers here are counterclockwise, also semi-dyslexic with the 10 as a 01. She kept becoming confused at the time... first it was 11:10, then 3:00, then 5:30 and her hands are closer to that than anything. Ironically, she was wearing a dial watch at the time.

The Alzheimer's Reading Room is not my favorite blog, but I do follow it regularly. I was impressed at this recent entry that described the author's change in his caregiving style as he learned about Alzheimer's Disease. The emphasis on the power of DOING is great, and I wish that this would become well-known. The case is similar for adults with Alzheimer's, people with disabilities, children, ANYBODY- "Let me do."

Saw this calculator (thanks to the Alzheimer's Reading Room) to figure up long term care expenses for different regions. I can't seem to make it work since I can't select cities, but this may be a function of firefox, hopefully not of the program. Anybody who can work it, let me know if it's a reasonable estimate compared to the real world.

Been reading some more on Alzheimer's lately. I have HBO's "Alzheimer's Project" on my DVR but haven't gotten around to watching it yet... but here are some other notes of late.

I have been reading about the Home Environmental Skill Building Program during my metro trips, which has been interesting. I can't use it very well in the hospital environment, but it would be good in home health as long as you could justify the billing. It has had some good insights for me anyway, namely, the understanding of different priorities between OT and caregiver.

If this article about early-onset Alzheimer's doesn't scare the crap out of you, you don't worry like I do... yikes. I have a lot of word finding difficulties, so my paranoia is bumping up now.

Stumbled onto The Alzheimer's Reading Room while looking up something else, it will probably become one of my top blogs in the scrollbar. I found it because I had read about the Test Your Memory exam on a Medline press release and wanted to see what was included in the test. However, after looking at it, I think we need an adaptation for the US... don't tell my history teacher father, but I'm not sure that I remember when WWI started. I would pick the JFK assassination as a seminal date in many of the current elderly individuals' minds, however, I don't know if there is a reasoning behind the date that it shouldn't be something the person actually lived through.

Saw 2 clients w/ dementia today, one early-stage and one end-stage. Depressing. Early stage lady was faking it pretty well but had severely decreased short and long term memory. Independent w/ BADLs though, so I am recommending adult day care, hopefully that will work out well. My end stage lady was a social admission... 92 y.o. husband came in w/ a cardiac emergency and she can't care for herself. Sweet lady, but gets confused in the middle of her sentences. She was good at ADLs too though. Long term care for her. No one likes to see their mother's mind crumble.

I've been trying to spend a little more time on OT Connections, especially in the posting department as opposed to lurking. Here's some topics that I have found interesting in the past few days.

You will have to be logged into OT Connections for the links to work- membership is free, you oughta be a member!

Food for Thought- a really good student project involving nursing home residents having greater control over meal time

Documentation on PDAs- a home health group is going paperless

OT Practice Discussion Forum- anyone can post topics now, I will probably x-post some thoughts on articles both here and there

Oncology Research Articles- I am looking for good rehab research relating to pts w/ cancer

Activity Book for Alzheimer's Patients- Barbara Smith shares her method for creating an activity book, some good suggestions on the thread

SI for Geriatrics- some good information about bringing sensory strategies to the older adult population

Hope that this is a good jumping in point for anyone who hasn't taken the leap into the OT Connections networking pool. Anything else captivating your interest on the site?

I am by nature, a total packrat in real life. I am even worse on the internet, as my bookmarks folder is now overflowing waterfall style! So here come the WebGems- with a focus on geriatric issues.

First off, some good news- TKRs do improve I/ADL function for elderly individuals! So it will be worthwhile in the end- but remember, it will HURT!!

This an ADVANCE piece on Elderspeak. It can be a hard habit to break, and usually requires me to write down all my patients' names until they're familiar to me, but I think people respond better when talked to appropriately. Different facilities have different policies... when I was on my Level II's we were on a first name basis with all the clients, to the point where one place had first names, last initial, on all the wheelchairs. At my current employment we're supposed to use Mr/Ms Last Name, but usually when I ask people what they would like to be called, they give their first names. My only confusion has been with having priests as patients... the ones that I have had (who knew each other, ironically) both asked to be called by their first names, but then I got dirty looks from people who thought I should be addressing them as Father X.

This Medline article implies that they're getting better testing for evaluating a person's driving ability. (Hope it's better than the Portoglare!) No mention of OT driving rehab or Carfit. This test is pretty extensive though, and the main problem is that they're describing it as a test for people with Alzheimer's Disease. It would be hard enough to get a person to agree to take this once, but they're certainly not going to want to keep taking it every year to satisfy that they're capable.

In other AD news, there are reports of a lot of caregiver abuse. This should add to the case for better respite programs and support systems for elderly aging in place and caregivers in general.

Romance is an issue from birth to death. This editorial reflects on falling in love after aging. And this piece is an interesting look at love in an ALF and the complications involving the family and staff.

And lastly, this editorial by an internist looks at how complicated it has become to die in a world of MPOAs, full codes, and feeding tubes.

There is a not-so-well-known, not-so-good movie called Wild in the Streets for which the play on words for the title is from. In the land of that movie, my day definitely would not have happened since the elderly were shunted off into communes, but since we don't really live there, feel free to continue reading about the craziness that has been Wednesday.

Wednesday starts for our purposes when the evening nursing shift came on at 7pm. In 12 hours, Mr. L will cause enough disturbance that there will be 15 different nurses notes written about his exploits. He will be found wandering in the hallway carrying a sheet and/or the room's courtesy curtain. He will dismantle 2 bedchecks, take the bolts off a geri chair, and also climb out of a geri chair with the tray attached without a scratch. His mini-mental scores are stable, at the very lowest regions of the Moderate Cognitive Impairment range. He has been speaking very tangentially, somewhat in nursery rhymes, and has identified our president as "Muhammad." He has been very emotional and has yelled at the PT several times this week, today he was pleasant with me for 25/30 minutes while he petted his dog (not a real dog). Mr. L decided to take a walk while I was present, and I barely had time to throw a walker in front of him and couldn't get to the gait belt... had to walk side by side with my arm around his waist to keep him on his feet. He has been in this fugue of confusion since his most recent surgery- he has no history of dementia. Hopefully someone can figure out a cause and reverse this process.

Ms I is 96 and has advanced dementia with the delightful combination of severely decreased vision (macular degeneration) and decreased hearing. She is disturbed by visual hallucinations and is terribly frightened of being left alone. She has been in a geri chair by the nurses station for the better part of 2 days so that she has 'company.' She started sundowning today really badly, calling out in a cat voice about being left alone during shift change. Her new roommate has had cancer and uses a kerchief to cover her head. Roommate said to me that Ms I thought she was a man when she took off her hat, but roommate was perplexed, since Ms I wears a wig and/or kerchief too. Roommate told nurses at some point last night "either give her a tranquilizer or give me one."

New admit today... (I forget her name, I did 5 evals this afternoon and hers was the last at 415) we'll call her Mrs T who also has dementia but is oriented, sees Ms I in the hallway and during those 5 minutes that they were around each other Mrs T got at least 75% more confused. I did the home safety cards with her yesterday, she had some interesting responses. She could spot some of the simple stuff, but when I asked, "Should she take this medicine that expired 10 years ago?" she didn't really know. This lady has been in acute care and thought that she was going home for the past 3 days... hope that she adjusts ok to the SNF floor. She may have to adjust to placement, but we'll hope for the best.

Twice I had to intercept the same pt. in the hallway this morning... once he was pushing a chair out in the hallway ("to get it out of the way") without his oxygen when he should be wearing 4 liters. He has no diagnosed cognitive impairments but lacks insight into his deficits and consequences. We barely made it back to his room without falling, and he made a grab for the curtain and I thought we were going down for sure then. 20 minutes later, I walk by and he hands me a "sputum sample" on a piece of gauze. The nurses didn't want it, I certainly didn't want it... BLEH.

Bad enough to have seriously cognitively impaired patients that require constant supervision for everything... adding in those who are just overly demanding or lacking in insight has made it hard to get much done. Did manage to discharge a couple of patients today, which is fortunate, because this has been a difficult week for the nursing staff and for meaningful therapy interactions. I have some time off, followed by some more time off soon, so hopefully everything will be on the upswing.

On a totally random note, I consider myself pretty "with it" in terms of technology, in fact, I am the resident computer dork of the rehab staff. (Fun fact- I had my first website when I was 15 and still remember random pieces of HTML code) I have a facebook account and utilize other internet technologies with ease, but I am having major difficulty figuring out OT Connections. I can't seem to join groups and am not finding other people that I know are on there. Perplexing. Also, I do continue to have issues making the cut links work well on this blog, but I am working to fix that since it makes my main page look all weird.

There's definitely an adjustment period to working in a hospital. Figuring out all the codes to the different supply rooms, learning the tricks to manhandling trays and hospital beds... it's those kinds of skills that come with practice. But until it becomes second nature, you still have a lot of things to check at the end of session. Here's some things that you should remember to check before leaving a pt after a treatment session to keep them safe and happy. Applicable to hospital and SNF rooms, a good checklist if you're new to the environment.


Ideally, you should just be reversing everything from your session so that the person is in the same condition as you found them, however, it's good to remember these things as there are often moments a person is without a crucial item.

• Bed brakes locked, bed height lowered
  
• Top 2 siderails up (some facilities have a policy against this, mine is all for it. If your individual had all four rails up, recreate that)
• Bed/chair check applied (as applicable)
• Tray table either parallel to bed or across pt's lap (helps keep everything within reach)
• Call bell in reach (can tie to bedrail or clip to sheets)
• Phone in reach, attached to bedrail
• Urinal in reach (I try not to put these on the tray... germy)
  
• Restraints applied (as applicable- generally if the person has UE restraints I only have one arm out at a time. Also remember those bedrail covers)
• Abduction pillow and other braces applied (as needed)
• Oxygen on person and turned on at wall (as applicable)
• Empty BSC or bedpan if it was part of your tx
  
• Any changes in status or other requests reported to nursing

That's about all I can think of now... it's actually easier when in the room instead of at a computer. If I forgot something major, just add it in the comments.

So one of my first OT moments while at home was at my grandmother's house. She had a tub to shower conversion done about a month ago to replace the 19 y.o. metal stool she had been using as a tub chair. Sounds great, but there is more after the link...

this is what the new shower looks like-

and in theory, it is the 100% solution. However, my gram is 5'2" and only her toes can touch the floor while sitting on the built in bench. She knew this when the guy was installing, but he said it was as low as it could go and he couldn't do anything and there wasn't anyone there to make a suggestion. My thought was that during the install he could have rotated the seat 180*... this would have kept the piece aligned with the studs, and though we would have lost a small shelf, it would have lowered the seat. Where it is now prohibits the use of any other shower chair, especially because the rest of the floor is slanted for the drain. I really can't think of what to put down on the floor so that she can gain some more stability and not slip off the seat. We thought of those shallow crates they use for 2-liter bottles, which are about the correct width to fit in the shower base, however those things would hurt your feet!

So I'm calling out to the OT world, especially those who are in home mods- how would you fix a shower that's supposed to have already been fixed? I can't think of the solution- what do you think?

OT WebGems charges on like a hybrid car rolling downhill! Ok, "brain" is a pretty broad term for an edition. The following links are mostly CVA related, with some NON-controversial information on stem cell research, and a couple of other thinly related articles. Who doesn't like neuro-know-how? Onward!


TIA Diagnosis- Neurologists have found 3 indicators to help avoid misdiagnose TIA. Briefly, if the person has had a slow onset of symptoms, vague symptoms (w/ or w/o neurological symptoms) and/or if a TIA had previously been ruled out at another time, then it is not likely a TIA. We do get therapy orders for pts w/ TIA, though they sometimes turn into a 'walky-talky' (as the speech therapist calls it) before we get there. I did get eval orders on a person who I had discharged on eval the previous day as she continued to have neuro events while in the hospital.

Stroke Centers- This study found that pts who received care at a specialized stroke center recovered better and stayed better than those who had care at a non-specialized hospital. They recommend telecommunication for rural hospitals, but I wonder if they explored the SES factors of their participants, as there can be some major overall health differences between city-dwellers & others who can get to a specialized center and those who are in a more rural environment.

Brain Implants- Scientists have found that there is some same-sided brain control over body movements, and are using brain-computer interfaces to help overcome hemiparesis. They can't leave the implants in long-term though... yet. Also, if you have not yet looked at BrainGate, you should definitely check into it. One of my classmates found this in late 2006, and they have continued to improve their research and tests.

Reprogramming Adults' Cells- Scientists have now taken a fully developed adult cell and transformed it into a different type of cell. This isn't super-new, especially because one of my former fieldwork CIs had a pt who had an experimental procedure where stem cells were used from his nose to help him overcome a paralysis. But, very cool.

Google- This was an interesting article about brain scans done in older adults during web surfing, but I think they missed a discussion point. It was the web-savvy users who showed the greatest brain activity during surfing, which I would think means that people need to develop their 'brain-gain' activities early in life and continue them, or that you would get less benefit from starting one of those activities later in life and being less skilled at it. I'm not sure if that really fits with what we already know about brain development though.

Amnesia- I throw this in here as a short, less-scientific but good intro to neuro article addressing amnesia and whether one knows they have it or not. Just happened to come across it while writing this.

Body Snatchers!- Scientists were able to create an illusion of body swapping between a person and a mannequin, tricking the brain's sensory perceptions. A cool jumping off point for robotics, VR, and possibly sensory reeducation?

Every now and then a pt. says something so cute, personal, or touching that it just tugs at the heartstrings... here are a few.

I have a pt. now who has Parkinson's Disease. She has a 3 story house with the only bathroom on the third floor. Her husband of 57 years carries the BSC up and down the stairs every morning and night for her.

A 12 y.o. w/ Osteogenesis Imperfecta is receiving PT. He had a recent fracture and told his PT, "I was doing so good... I made it all summer without breaking anything!"

In a family meeting, an elderly man's children were trying to get him to adopt some safety measures, including not going up and down the steps. He likes to meet his Meals on Wheels deliverers at their car, and when it was suggested that they could bring the meals in, he said, "but some of them are in bad shape!" He also likes to use the steps to sit outside and feed his squirrels, which he has been doing daily for 45 years. When his family tried to say that they only wanted to make changes that would be helpful for him, he said, "how can I trust that you'll do that when none of you even feed my squirrels? They watch me eat breakfast by sitting on the skylight and will eat out of the palm of my hand, and none of you even put a tray out for them!" This man has such a deep affection for his woodland friends, even used to feed them with his now-deceased wife. It was really touching, but sad since he was obviously upset about the care the squirrels had received. He went home last week, so hopefully things worked out well for him.

In other news, I have had 3 work related dreams in the last week... not cool. Don't need to carry the stress home.

The hospital has actually been slow for a little while, but I couldn't catch a break during that time since my pediatric caseload was simultaneously growing. The peds caseload will require a separate entry, as it has exploded a bit. Anyway, the circle of hospital life always comes back around from slow with only a few pts to overfull with referrals coming out of our collective ears. We've managed to fill up again just in time for us to be shorthanded as a colleague takes a weeklong trip. But, before I get totally overwhelmed again, here's some stories on a few of the interesting people I've seen recently.


I have been working with Mr. H for the past 2 weeks. A great elderly gentleman who is mentally extremely sharp. I believe that he remembers absolutely everything I have ever told him (so hopefully he will remember to get those grab bars installed at home!). Really nice guy, good sense of humor, and absolutely tries his hardest to work with us. He came in with a hip fracture and a previous dx of Parkinson's Disease. Thank goodness that he had an ORIF, as he has a special method of mobility that would not work at all if he had hip precautions. He's become one of my favorites, which is good, because since he moves slower it takes considerably more time to do a treatment. He has progressed from being MAX Ax2 to stand, also for LE dressing, to being CG-SBA. Terrific progress.

Mr. R has also had a strange journey that I've gotten to share. He had a history of problems with his shoulders and had 1 rotator cuff surgery a long time back. It had taken him a long time to recover, but he did get a lot of UE motion back. Then, over the course of a couple months, he gets run down, stops exercises, has some cardiac issues and pneumonia and winds up in the hospital. When he first arrived on our skilled unit, he had such minimal ROM in his arms that he could not use them to help stand up, and was MAX A 1-2 for all ADL tasks. We had really made some progress, and he was able to dress upper and lower body w/CG-MIN Ax1 and was looking ready to discharge soon. Unfortunately, he had a bowel obstruction, wound up back in acute care for a week. He's been readmitted to the skilled unit now and hopefully hasn't deteriorated too much in the interim.

Most complicated evaluation of the week goes to Mrs. MA, who had a very intense CVA. She had multiple infarcts in the L MCA distribution in the frontal, parietal, and temporal lobes. This also resulted in mass effects, which usually happens in hemorrhagic CVAs, not ischemic. First thought: Holy cow!!!! This lady has expressive aphasia, and is limited mostly to the word "okay." On the day that I saw her for the eval, she was doing a little better, using a few more words appropriately and trying to construct sentences that would start out intelligble. Us "Thurapee Girls" descended en masse- OT, Speech, PT. We got her OOB and into a chair, at which point the telemetry nurses descended upon us freaking out- Mrs MA's heartrate was 190. So, back to bed, PT exited stage left, and I did my first cotreat with our new speech therapist. It's terrible to say that I've had fieldworks and been practicing over a year and never cotreated with speech, but it's a situation of coincidental circumstances and not out of some crazy "no teamwork" philosophy. I do cotreats w/ PT all the time, but really had to switch my brain channels for working with speech. Challenging, but fun! We worked on communication briefly, and worked feeding and groming into the bedside swallowing eval. Also, I learned a new fun fact- no cranberry juice for people on Coumadin. Good to know. I hope that this interesting lady makes a good recovery while she's with us... she'll likely discharge to community SNF or maybe acute rehab if she starts doing better.

Also have another TKR pt. who is going to recover function much faster than knee flexion or mobility. She's mobidly obese, but has excellent flexibility (way better than me) and can do lower body dressing in bed. That's not usually something I do with people who do not have a spinal cord injury, but it works. However, she's still struggling a lot with basic mobility and knee ROM. We will likely see her on the skilled floor.

Here's hoping we don't get TOO busy... since that takes away the time that we can spend on each person and simultaneously takes away my sanity. :)