Sunday, March 29, 2009

Drawing the line

How to determine when a patient is going to be safe to go home when they have short term memory loss.
I have a patient at the moment who is the primary carer of his son who has an ID. He is 86 with an HDS of 160/200 primary impairments in attention and memory. The family is very supportive and they wish for him to return home..however the team in particular the nursing staff dont think he should go home. The patient has alot of support for personal care and domestic tasks but the primary issue is his memory - to remember to take his meds, pay bills, and remember to heat and eat meals.

I am yet to talk to the family (particularly his daughter) but i plan to ask what types of things they supported him with pre-admission and discuss the support he will need to compensate for his short term memory impairment.

I have liaised with the SW and the only problem the family has from a SW perspective is the amount of support they have at home. I am concerned about the patients ability to "be a career" for his son - and what this entails - as his primary role at home it is important from an OT perspective that he is able to do this. This is something i plan to investigate

Im still unsure "completely" if this patient is safe for discharge - obviously they will need supports with taking medications (whether this is a daily phone call to check or physical assistance or an alarm). And similar for ensuring the patient is eating appropriately.

Once the situation is decided i will also need to check out the home environment to ensure that it is physically safe for discharge as he has SOBOE ++++

Saturday, March 14, 2009

The question that stumped me

I was telling dad about an interesting experience that i had had at work and he asked me the strangest question...

"How do the people react to you when you are working with them when you are alot younger than them?"

At first i was stumped i didn't know an intelligent answer and the first thing that came out of my mouth was...

"What do you mean? I work with people and havnt noticed any issues with age"

I have thought about this more and considered why it was that i had never thought age was a problem. Firstly i have only been older than a few patients as an OT over the last year. Thinking back i dont think age changed how i approached them as a person. I approach everyone the same - with respect for their experience

I dont think it matters how old someone is but i believe that you get what you give. If you on in to see a patient and respect them, listen to them and be open and honest - then you'll get that back in return. So age to me doesn't matter, whether 20 or 90, you get what you give (most of the time)

The fact that my dad had asked me this lead me to believe that perhaps he would fell uncomfortable with a younger person working with him, giving them advice or discussing professional things. Hes an ordinary man...maybe people i have worked with have experienced a negative feeling about working with a younger professional. This is probably more common than i realise. I guess everyones unique but i had hoped that i could use my interpersonal skills and therapeutic use of self to allow the patient to feel comfortable and working with me, and gain a working professional relationship.

So how do i make this happen?????
WEll i have already mentioned respect, but also clear and open communication, ethical principles such as autonomy and informed consent.. On a broader level CCP!

This is so important and yet took some digging to get out and i realise just how embeeded these core elements are in "what i do"

The other thing that has popped into my head and is equally important is CONFIDENCE and COMPETENCE

I realise that there are things that i "know" and things that i dont! But i also believe that competence goes hand in hand with confidence. If i had competence in working with a patient about a particular topic or issue or diagnosis or functional issue then only could i have confidence working with the patient! However on the swing side of things - if a new grad presented as confident in doing something - this doesnt necessarily mean that they are "competent"...

Why does confidence and competence matter when working as a young professional???

Lets say i was unsure of how a cognitive impairment was likely to affect a patients safety at home...
There are two things that i imagine i could do..
(1) - Go in and see the patient confidently and say it (not really understanding what you are saying)
(2) - Go in with no confidence saying "im really unsure but i will find out for you"
(3) - Seeking advice and then going in confidently (knowing you are competent) and disucssing it with the patient and educating them ..

One guess what the best thing to do is - but anyway what im trying to explain is that low levels of confidence will negatively affect how the patient feels when working with someone whom is younger - therefore seeking advice, support etc is vitally important to ensure that issues of "age" or competence more in fact do not become an issue!

Thursday, March 12, 2009

The importance of family communication

If i hadnt had utilsed the opportunities to talk with the family of a patient i wouldnt have found out so much VITAL information!!!!!

A man who i have had a lot to do with over the last week on the medical ward is to me a "mystery man" But when i talked to his family to see what he was like pre-admission/pre-becoming unwell i wouldnt have linked the vital info together.
Talking with the family enable me to how his personality had changed. But more importantly they gave me some insight into their concerns and what they had observed on the ward.

I had realised and observed that this patient had difficulty initiating tasks/actions/activities but i had not realised that the nurses had not been supervising his ADLS including eating, showering, dressing and grooming. Therefore he was not attending to these basic tasks at all! How awful!

As a result of gathering this information is was soooo important that i handed it over when he went to rehab! They also had some vital information that would have been helpful when he was admitted - that he had been using a diary and alarms for reminding him of things (so therefore he was aware of his memory decline and was compensating for this impairments well before he was "brought" into the hospital by this colleague.

Up until now his diagnosis has been a mystery - various tests had not confirmed anything - still not confirmed but from my opinion (personality changes/cognitive issues) maybe this was Dementia of some type i have no idea..

TO some up - this example really illustrates the importance of working alongside family members, how vitally important they can be and how communication between team members and family is necessary.

Tuesday, March 10, 2009

Case review An interesting case, and interesting presentation and no diagnosis

Gender/age/primary diagnosis - Male/57/No diagnosis ? CJD/delerium/neurological
Reason for referral - confusion, poor attention, for cognitive assessment
Medical Hx: Nil
Social situ: Lives alone, separated, 2 adult daughters in location
Occupation: Real estate agent
Prior OT input: Nil
Supports before admission: Nil
How managing before admission: Fully independent, high functioning being
Assistance on ward (mobility/self cares): Independent mobility, Supervision/assistance with self cares

OT input this admission/ Assessment(s): Initial interview, cognistat, kitchen assessment, discussion with daughters, physio and medical team

Problems identified:
(1) Poor attention/concentration
(2) Trouble initiating tasks/steps/action
(3) Difficulty with searching/locating and problem solving
(4) Slow information processing
(5) Frustration/emotional
(6) Difficulty planning, organizing and sequencing (? terminating)
(7) Poor standing balance
(8) Difficulty with verbal information/prompts

(1) Insight into cognitive limitations
(2) Wanting to return to work - motivated
(3) Remembers OT on a daily basis, remembers when his daughters have visited
(4) Mobility and awareness of balance problems

Goals for rehab:
(1) Getting a diagnosis
(2) Returning home
(3) Returning to work (eventually)
(4) Work on problems identified

Mr W is very frustrated and emotional in regards to his cognitive issues - he is aware of some of his limitations and realises he is unsafe to go home. He is upset that no one knows what has happened to him and he is finding it hard to cope with his changes in function.
Mr M has agreed for a period of rehab to sort out what is going on and to help him "get better"
Mr M has agreed for the vocational OT to become involved to help him return to work

Monday, March 9, 2009

Dysphasia in more detail

Features of dysphasia

Dysphasia can be seen as a disruption in the links between thought and language. The diagnosis is made only after excluding sensory impairment of vision or hearing, perceptual impairment (agnosia), cognitive impairment (memory), impaired movement (apraxia) or thought disturbance as in dementia or schizophrenia. When testing for dysarthria and dysphasia, the patient%u2019s ability to repeat or produce difficult phrases or tongue twisters can be indicative.

People with receptive dysphasia often have language that is fluent with a normal rhythm and articulation but it is meaningless as they fail to comprehend what they are saying.
People with expressive dysphasia are not fluent and have difficulty forming words and sentences. There are grammatical errors and difficulty finding the right word. In severe cases they do not speak spontaneously but they usually understand what is said to them.

Specific types of aphasia are associated with damage to particular cortical regions but in practice distinctions are not always clear. Language is a complex activity involving many cortical and sub-cortical areas and lesions do not dissect clearly demarcated anatomical areas. Generally, expressive dysphasia suggests an anterior lesion while receptive dysphasia suggests a posterior lesion. There are a number of sub types. They are:

* Sensory (Wernicke's) aphasia - lesions are located in the left posterior perisylvian region and primary symptoms are general comprehension deficits, word retrieval deficits and semantic paraphasias. Lesions in this area damage the semantic content of language while leaving the language production function intact. The consequence is a fluent or receptive aphasia in which speech is fluent but lacking in content. Patients lack awareness of their speech difficulties. Semantics is the meaning of words. Semantic paraphrasia is the substitution of a semantically related but incorrect word.
* Production (Broca's) aphasia - lesions are located in the left pre-central areas. This is a non-fluent or expressive aphasia since there are deficits in speech production, prosody and syntactic comprehension. Patients will typically exhibit slow and halting speech but with good semantic content. Comprehension is usually good. Unlike Wernicke%u2019s aphasia, Broca%u2019s patients are aware of their language difficulties. Prosody is the study of the meter of verse. Here it means the rhythm of speech.
* Conduction aphasia - lesions are around the arcuate fasciculus, posterior parietal and temporal regions. Symptoms are naming deficits, inability to repeat non meaningful words and word strings although there is apparently normal speech comprehension and production. Patients are aware of their difficulties.
* Deep dysphasia - lesions are in the temporal lobe especially those mediating phonological processing. Symptoms are word repetition problems and semantic paraphasia (semantically related word substituted when asked to repeat a target word).
* Transcortical sensory aphasia - Lesions are in the junction areas of the temporal, parietal and occipital areas of left hemisphere. Symptoms are impaired comprehension, naming, reading, writing and semantic irrelevancies in speech.
* Transcortical motor aphasia - lesions are located between Broca%u2019s area and supplementary motor area. Symptoms are transient mutism, telegramatic, dysprosodic speech. Telegramatic means omitting unimportant words, as was done when sending a telegram. Dysprosodic speech is monotone.
* Global aphasia - occurs with extensive damage to the left perisylvian region, white matter, basal ganglia and thalamus. Symptoms are extensive and generalised deficits in comprehension, repetition, naming and speech production.

Revising dysarthia and dysphasia

Dysarthria is a disorder of speech whilst dysphasia is a disorder of language.

* Speech is the process of articulation and pronunciation. It involves the bulbar muscles and the physical ability to form words.
* Language is the process in which thoughts and ideas become spoken. It involves the selection of words to be spoken, called semantics and the formulation of appropriate sentences or phrases called syntax.

Strictly speaking, the words anarthria and aphasia mean a total absence of ability to form speech or language but they are often used when dysarthria and dysphasia would be more correct.

Dysphasia can be receptive or expressive. Receptive dysphasia is difficulty in comprehension whilst expressive dysphasia is difficulty in putting words together to make meaning. In reality there is usually considerable overlap of all these conditions but a person who has pure dysarthria without dysphasia would be able to read and write as normal and to make meaningful gesture provided that the necessary motor pathways are intact.
Inability to write is agraphia or dysgraphia if incomplete. Inability to manipulate numbers is acalculia or dyscalculia if incomplete. Difficulty reading is dyslexia.

Wednesday, March 4, 2009

Frontal lobe dysfunction

Recently i have worked with a patient who had difficulty organizing herself ? problems with initiation, and severe short term memory impairment.

I linked this all to frontal lobe damage and found a wonderful website (link below)

I am particularly interested in motor planning and the dysfunction of dyspraxia.

Dyspraxia is the inability of the brain to conceive, organize and carry out a sequence of events. In particular the inability to self organise.

During my assessments with this patient i noticed that the ability to organize was difficult.
For example i asked her to get her things ready for the shower. She went over to find her clothes and could not organize this and required verbal prompting. She was searching though her clothes but was unable to pick and choose the clothes she needed. She also required verbal prompting to organise her toiletries and get herself off to the bathroom. I think she would have taken all day with out prompting and don't know if she would have been successful after that.

Initially i thought it may have been difficult for her to choose the clothes - she had an idea of what she needed (she said i need a singlet, and knickers) but was unable to search - she may have had a plan of what she had to do but she couldn't execute this plan. She kept picking things up, putting them away and couldnt choose items of clothing.

On another occasion during a kitchen assessment i asked her to make a cup of tea. Everything was all organized for her and this was alot easier - everything was laid out in front of her and i introduced her to the environment. However this time i had some concerns as she was troubled with interacting purposefully with the environment. E.g. she picked up the jog to pour tea into the cup but didnt realise that she was ment to pick up the teapot that she had been waiting for.
This could have been memory - but i thought it was more to do with noticing environmental cues.

I would be interested in talking about these cues and my hypothesis further in supervision more to make sure i have got to grips with what a deficit in motor planning looks like, and to discuss other "obvious" observations that could arise in the future.

Tuesday, March 3, 2009

Case review - performance components

Gender/age/primary diagnosis - Female/86/Compression # T12

Reason for referral - OT review decreased mobility

Medical Hx: Macular degeneration/Angina/AF/Bilat TJHR/Diverticulosis

Diverticulosis is a condition where pockets (pouches) form in the large intestine (colon).
Macular degeneration results in a gradual distortion of central vision, and sometimes leads to a central blind spot called a scotoma. When central vision is impaired, you may have difficulty recognizing faces and colors, driving a car, reading print, or doing close handwork, such as sewing or other handcrafts.

Social situ: Lives alone/Family supportive live close

Prior OT input: Rails installed by ACC for husband in bathroom, toilet and access

Supports before admission: HH 1/7

How managing before admission: I with ADL's ? unsafe cooking meals due to MD

Assistance on ward (mobility/self cares) - Supervision with mobility, Assist with transfers chair/bed/toilet.
Indep with upper body washing/drying/dressing
Assist with lower body washing/drying/dressing

OT input this admission/ Assessment(s): Initial assessment, transfer assessment, disussion with RN and Health care assessment

Problems identified:
-Unable to stand for long period of time
-Decrease vision ? safety at home for cooking meals (issue prior to admission)
-Assistance with lower body cares
-Assistance with transfers 1X

Goals for rehab:
-Increase independace - selfcare/transfers
-Pain management
-Increase standing tolerance
-Assess home situ re: safe for dishcharge re: visual impairment

Recommend for rehab
Handover to rehab team

Pt is happy to go to rehab for a week or two and increase her independance. She will most certainly require a home visit re: safety with cooking at home, and home environment.

Performance Components:

Sensory: age related hearing loss/macular degeneration(loss of central vision)/nociceptive - back pain, elbow and shoulder pain during shoulder flexion/extension/ mild hip pain

Physical: Good posture when supported; reduced ROM in R elbow and R shoulder; reduced strenght in arms for transfers; moderate endurance; visual motor eye hand slightly inpaired

Cognitive: now problems with attention/concetration/insight/orientation - nil others assessed

Percpetual: (Visual) recognition of faces/objects/words/colour; colour disccriminations; figure ground; pattern and shape recognition/matching

Perceptual: (Spacial) Depth percpetion; percpetion of angles and levels

Social: Little expression or gesture/emotion/

Monday, March 2, 2009

First Cardiac Rehab Group - relaxation

Well took the group today and it went really well

First i welcomed everyone and introduced myself, then checked to see if there were any new people. (there were note) If their was i was have talked about the benefits of relaxation more indepth. Instead i just mensioned the following:

Decreasing heart rate/rate of breathing
Lowering BP
Reducing physical fatigue
Improving ability to cope with tension, stress and pain
Can reduce frequency of headaches
Improve circulation to skin in muscles

So then i asked for feedback on last weeks session and asked if anyone had tried the techniques out for coping strategies with sleep problems..wasnt a great response however one person said that the thought stopping didnt work! But i reiterated that some things you find good, and some you dont - its about finding the one that works for you but not giving up on one if it doesnt work the first time because relaxation is a "learnt technique" and practice makes perfect.

Then i introduced visualisation as a technique - e.g. used for visualising yourself in a calm relaxing state, and it can also be about going in to a place that is peaceful and quiet.

Then we did the staircase relazxation technique, followed by discussing how everyone felt the technique went.
We got a good converstation going about how you know when you are relaxed as a man fell asleep! So i emphasised that relaxation techniques are working if it relaxes you to a point that makes you fall asleep.

I also added that if you were not interested in buying the tape/or didnt have anyone to read it too you then prehaps trying doing some deep breathing and practice visualising the quiet peaceful, special place and counting yourself down the stairs and think about the sensations of the place and relax all the muscles in your body. People seemed interested in doing this - or showed they understood what i was telling them.

All in all a good session - looking fwd to nxt week, and getting feedback about the process i used today

I was confident in talking and didnt get my words all mixed up. I had prepared myself with the information so i wasnt stuck for words.
I was able to get some discussions going but i guess its hard when people come in and out of the group. Anytime discussing is good time and it was good to hear their percpetion of how well things worked.