19/4/2015 Being ADL dependantThe following was a case study by my colleague in the family medicine fellowship course we attended. We would post our case studies via email and then our colleagues would provide feedback. My colleague case is colored re while my comments are in black
Background and Past Medical History Mdm A is a 74-year-old lady with hypertension, hyperlipidaemia, ischaemic heart disease and a left middle cerebral artery (MCA) infarct , after which she was home bound but able to furniture walk at home and be independent in her basic activities of daily living (ADLs). She then suffered a new catastrophic left MCA infarct secondary to new onset atrial fibrillation, which unfortunately left her chair to bed bound, and requiring moderate to maximal assistance in all her ADLs and requiring a nasogastric tube (NGT) for artificial nutrition and hydration. As she had previously indicated not to go to a nursing home, the family respected her preferences and caregiving duties rested with her eldest daughter Ms B who was single. Mdm A was referred to rehabilitation hospital for a period of slow stream rehabilitation and caregiver training. During the admission, she was also started on fluoxetine 10mg OM for depressed mood. By discharge, she was able to sit out on a geriatric chair and stand for a short period with 1 person assistance and a walking frame.
Progress of Case My first encounter with Mdm A was to review her at my outpatient clinic two weeks post-discharge. Mdm A was a thin, frail-looking elderly lady wheeled into the consultation room by her tired-looking daughter Ms B. I realized my first challenge was communication with the patient. She had documented mixed aphasia (expressive > receptive) secondary to her cerebrovascular accidents. Although she appeared to understand what I was trying to tell her, most of the times she did not respond or would only nod her head after a long pause. Despite my best efforts to speak louder, slower and use gestures to improve communication, progress during the consultation remained slow. Aware that she must be equally frustrated at not being able to expressing herself, I reassured her that “it was ok”. I completed the rest of the medical history and physical examination with input from Ms B. Cognizant of possible caregiver stress; I interviewed Ms B on how she and the patient were coping at home. She was not coping well and felt stressed . There was much frustration caused by communication barriers and physical challenges in care. Mdm A had become more irritable and easily agitated when she couldn’t communicate what she wanted and would have temper tantrums and threw things. Mdm A did not want to participate in day care, and would spend most of her time sleeping or watching television. Ms B was also physically exhausted from managing the household chores and felt socially isolated as there was minimal help from other family members who have their own families and would only visit for short periods over the weekend. She had much difficulties preparing Mdm. A for her medical appointment today but decided to come because she needed help. Ms A’s plea to me was “Please apply a nursing home for my mother, she would be better taken care of”.
Discussion I was faced with the dilemma posed by Ms B request for a nursing home application. Although Mdm A had aphasia and depressed mood, I could not assume that she lacked mental capacity. All practical steps should be taken to help Mdm A adequately make an informed and voluntary decision. I assessed that she seemed to understand information but would require input from a speech and language therapist on her capacity to remember and weigh the information. If she lacked mental capacity, then her substitute decision maker Ms B should decide based on Mdm A likely preference or best interests, with consensus from her other siblings.
Is the nursing home option in Mdm OT’s best interests? On one hand, applying nursing home seemed the “easy option out” and would ensure medical and nursing care for Mdm A and relieve Ms B of her caregiver stress. However, considering her previous preference, admission to a nursing home would seem like abandonment to the old lady and devastate her psychologically. I also had the responsibility to be the gatekeeper of limited resources. Aware that Mdm A may be upset by further discussion about nursing home; I distracted her by getting my nurse to do her blood tests in the treatment room while I could have a private discussion with Ms B on other alternative options.
Mustering community and family resources to alleviate caregiver stress and avoid premature institutionalization In a rapidly ageing population like Singapore and with limited long term care facilities, informal caregiving by family members remained the major source of care for older patients with functional dependence. This heavy burden of caring fell onto the shoulders of Ms B, who also left her day job as a cashier. Without adequate support, many caregivers suffer from depression and poor health themselves. Although the plan on discharge was for Mdm A to attend the day care centre to improve her participation in social activities and relieve caregiver burden, she was reluctant to go after the first session as they could not understand her needs. I encouraged them to attend a few more sessions to get Mdm A accustomed to the routine and for Ms B to accompany her mother to observe the activities at the centre. The day care would also provide much needed respite for her. I organized senior home care to assist with the household chores and showering of Mdm A on non day-care days. On encouragement, Ms B agreed that she should request for her siblings’ assistance in caring for Mdm A. We made a shared decision to try out this new plan for the next two weeks to see if Ms B would be coping better. Improving communication with aphasia patients and involving the speech therapist in the care Communication with aphasic patients can be difficult; and physicians often neglect the patient and turn to their caregivers for information. My communication with Mdm A during the first consultation could have been better. I did a literature search and approached my speech and language therapist to discuss the case and learn strategies to communicate more effectively with an aphasic patient. By doing a simple exercising in guessing what my speech therapist was trying to tell me using gestures, I appreciated the difficulties and frustrations aphasic patients faced in communications. Some useful strategies are: · Acknowledging patient’s competence to understand & communicate · Using simple sentences, reducing rate of speech and using active voice, reducing distraction, using gestures, emphasizing key words, writing main topic on big font, using pictures, real objects and resources, asking yes/no questions, speak and write /gesture to patient naturally and concurrently, encourage pointing / showing/ gesturing, placing objects within reach (e.g. calendar, map), give patient time to respond, and use yes/no card for patient to point to. · Verifying answers During my next consultation with Mdm A, I employed these strategies and also used the resources and aids , including picture diagrams to illustrate common questions in the history taking and answers. To assist Mdm A to respond, I gave her written choices to point to Yes/No or point to what she wanted. Lastly, I verified each of her answers to ensure that I did not misunderstand her. Gradually, Mdm A’s mood improved and she was able to attend day care sessions three times per week and group language rehabilitation sessions. The improvement gave Ms B much needed respite and avoided premature institutionalization. My reflections on being ADL dependant
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Q&AHere I post some of the more interesting questions I had been asked and the replies I gave. My replies are based on my knowledge and experience. I do not have the perfect answers. But it is my hope they bring some understanding to you. Archives
February 2017
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Materials excluding links on this website are not copyrighted. They may be reproduced and distributed without fees.