At Draper Rehabilitation & Care Center, we admitted a 79-year-old male patient with advanced Parkinson’s disease, referred to OT for wheelchair mobility. The patient recently obtained a power-assist lightweight manual wheelchair but has been unable to propel functional distances (to nursing station, dining room, activities, etc.). He demonstrates movements reminiscent of freezing of gait wherein he does not move for several seconds or minutes and appears stuck in place despite his efforts to initiate movement.

Research and Applications to WC Propulsion

Research on FOG reveals applications for WC mobility because freezing occurs in a variety of motor tasks, and UE kinematics have been shown to improve with the use of auditory cues.

OTs and PTs can innovate in low-tech and high-tech ways to apply this evidence to functional activities beyond gait. An example of a low-tech intervention would be attaching a laser to the wheelchair or using a bell, a metronome or music during WC propulsion. An example of a high-tech intervention would be designing a smartphone app that utilizes a smart watch or other sensor to monitor freezing and triggers visual cues or auditory cues. Therapists should also stay up to date on products that are in development and testing.

OTs and PTs can combine multiple sensory cues to increase effectiveness. OTs/PTs should also experiment with continuous and on-demand cuing.

By Amanda Call, MA, OTR/L, Draper Rehabilitation & Care Center, Draper, UT

At Magnolia Post Acute Care, there has been an increasing number of community-dwelling adults admitted to our facility with high prior level of function who are discharging back to the community. An interdisciplinary approach with both occupational therapy and physical therapy was used to identify appropriate assessment tools applicable to community reintegration and to use the indications from these tools to guide treatment interventions.

The assessment tools chosen focused on safety and fall risk as well as sit or stand balance, distance of ambulation or wheelchair mobility, safe functional reach, and overall safety awareness in the presence of high sensory demands in the community. Overall, our goal is to be able to create a comprehensive community reintegration program where patients can practice components of community re-entry in a safe environment.

Assessments Used

• The Functional Reach Test (FRT) addresses community activities such as retrieving items during grocery outings, opening doors, operating a crosswalk push button, accessing public transportation and managing money. This assessment determines a patient’s stability by measuring the maximum distance an individual can reach forward outside a base of support while standing in a fixed position. Results of this assessment were used as an indicator of fall risk.
• The Dynamic Gait Index (DGI) addresses more challenging aspects of balance that can be more relevant to community activities such as negotiating curb cuts, looking both ways when crossing a street, and modifying the speed of gait quickly due to changes in the environment. The Dynamic Gait Index assesses an individual’s ability to modify balance while walking in the presence of external demands.
• The distance of ambulation is also relevant. According to Brown et al. (2010), the 200-meter, or roughly 650-foot, distance is a good starting point for older adults with the goal of returning to community independence. According to Andrews et al. (2010), full community ambulation may need to be increased to 600 meters or more.

Results

Of the seven individuals, six were taken out to the community and ambulated to a nearby 7-Eleven store, which is approximately 1,600 feet round trip from the facility. This outing addressed money management skills, navigation skills, managing intersections, item retrieval, safety education and curb cut negotiation.

Upon discharge to the community:

• FRT — Using a cutoff score of 18.5 cm to determine fall risk (Thomas et al., 2005), six of seven patients’ scores indicated they did not have a high risk of falling.
• DGI — Using a cutoff score of 19/24 to determine fall risk (Wrisleyand Kumar, 2010), three of seven patients’ scores indicated they did not have a high risk of falling.

Discussion

With the use of these assessment tools, the therapists are able to examine the underlying physical requirements necessary for reintegration with the community. They establish an effective treatment plan from an evidence-based perspective with an interdisciplinary approach.

The therapists incorporated the use of compensatory strategies, alternative assistive devices, environmental supports and services, as well as referral to home health or outpatient therapy services in order to best reintegrate patients to their communities safely.

By Nicole Veniegas, MS, OTR/L, Kathryn Case, MOT, OTR/L, Harini Desai, MPT, Magnolia Post Acute Care, El Cajon, CA

 

Our IDT Falls Committee initially discussed the implementation of baby dolls for some of our long-term care residents with a high incidence of falls and elopement and who were difficult to redirect during care. We identified four residents for a trial use of baby dolls as a means of providing the residents with a sense of purpose and to redirect positive attention during their daily routine.

Our Process

Each resident was screened with both the FAST and GDS to determine cognitive staging.

• Resident #1: Stage 6 on the FAST, Level 6 GDS. She had frequent episodes of crying out for family and attempts to get out of bed, and she was combative during care.
• Resident #2: Stage 5 on the FAST, Level 5 GDS. She was often trying to elope, constantly looking for family, combative with staff and resistant to care.
• Resident #3: Stage 5 on the FAST, Level 5 GDS. She was depressed, looking for family and trying to get up on her own.
• Resident #4: Stage 6 on the FAST, Level 6 GDS. She was often looking for her deceased husband and waiting at the door for her children, and she often expressed wanting to die because she was a burden.

We determined it would be appropriate for these residents to take place in our trial use of baby dolls in the facility. Residents’ families were informed of our plan.

Our residents were all provided with ethnicity-specific baby dolls to increase the likelihood that they would relate to the doll they were provided. We monitored their ability to relate, their interaction with the baby dolls and their overall behaviors.

Findings

• Resident #1 was more easily re-directed, had decreased episodes of crying, decreased attempts to get out of bed, and decreased conflict and anger associated with her family.
• Resident #2 was interactive with her baby doll, but she continues to attempt to elope from the facility and look for family.
• Resident #3 experienced an effective dose reduction with psychotropic medications, fewer attempts to get up on her own and decreased verbalization of being sad.
• Resident #4 had decreased episodes of wanting to find her family and a decreased incidence of verbalizing wanting to die.

Plan

Daily Activities programming revolved around care for the baby dolls. The Activities Director provided diapers, wipes, clothing and blankets, and residents cared for their baby dolls during morning activities. Residents gained an extreme sense of satisfaction, care and purpose during this care.

We will continue to work with our psychiatrist on gradual dose reduction of psychotropic medications when appropriate. We also will continue to trial the use of baby dolls with other residents who may benefit from this programming.

Conclusions

The use of baby dolls has proved to be an asset in our skilled nursing facility. Our residents have a sense of purpose, are brought back to a nurturing time in their lives and are distracted with a positive outlet. We will continue to use baby dolls as a valuable part of our programming with residents who fit our criteria.

By Aimee Bhatia MSOTR/L, PAM, Glenwood Care Center, Oxnard, CA

 

“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” — Leo Buscaglia

Our Dementia Care Program was established to improve the quality of life of each person living with dementia entrusted to our care at Oceanview Healthcare & Rehabilitation. Our goal is to steadily increase the well-being of those we affect directly, while becoming an influential model within the community for a widespread shift in how we view dementia as a culture. Program objectives include the following:

• Preserve autonomy
• Ensure safety
• Promote dignity
• Maintain ability
• Facilitate active participation
• Encourage resident friendships

Programming Process

To meet the above objectives, we have a multi-step process designed to uncover each resident’s unique background, needs, wants and abilities. Our process includes:

1. Interviews to discover each person’s life story, unique experiences, hobbies and interests.
2. An assessment of physical and cognitive abilities as well as personal needs and desires.
3. Development of person-centered programs that preserve each resident’s abilities and enhance their quality of life.
4. Education and training for caregivers to ensure competency when implementing each program.
5. Completion of quarterly or biannual screens to re-assess abilities. If necessary, programs are revised and staff is retrained accordingly.

Research-Inspired Environmental Modifications

At Oceanview, the above process enables evidence-based integration of our dementia patients into environments alongside like-ability peers. We call these environments “neighborhoods.”

These neighborhoods enable us to customize care. Whether it be through activity planning or caregiver training, we emphasize preservation of ability, dignity and independence. By improving caregiver education, we are able to better prevent communal conflict, implement beneficial activities, encourage meaningful relationships and strategically modify environments.

Caregiver training, specific to each neighborhood, includes the following:

• Communication strategies
• Cuing techniques
• Behavioral strategies
• Estimated assistance necessary

At Oceanview, we pride ourselves on an “outside of the box” philosophy that enables us to maintain a person-centered approach while enhancing the well-being of all. Beyond this, we aspire to be a catalyst for cultural change by encouraging others to abandon the negative stigmas attached to dementia and emphasize the value and uniqueness of each distinctive life.

Submitted by Oceanview Healthcare & Rehabilitation, Texas City, TX