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Geriatrics

Introduction:

Changes that occur and impact on the elderly's occupational independence (ADL- IADL):

  • Physically:

1.     Vision

2.     Hearing

3.     Musculoskeletal

4.     Cardiovascular

5.     Pulmonary

6.     Urinary

7.     Digestive

8.     Immunity

9.     Skin

10.  Rest and sleep (circadian rhythm)

11.  Balance and stability (Fall)

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  •  Socially:

12.  Driving- community mobility

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  •  Cognitively

13.  Mental function (memory, attention, etc.)

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  •   Culturally

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An occupational therapist evaluates:

  • Vision

    • Perception

      • ​Clock test

    • Coordination

    • Visual field

    • Pain

    • Contrast acuity[1](high and low)

      • Snellen chart

      • ETDARS Chart

      • MN Read Acuity Charts

      • The Pelli-Robson Chart

  • Balance (same as neuro)

    • Balance berg scale

    • Balance assessment

  • Coordination (same as neuro)

    • Coordination test

  • Strength

    • MMT

  • Endurance

  • Safety awareness

  • Attention, Problem solving, Memory

    • MMSE, Mini cog, MOCA, etc.

  • Communication

  • ADL

    • FIM

  • IADL:​

  • Home assessment:

    • Home visit assessment (checklist)

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[1] Acuity is the ability to see small details and color.

Assessment of Motor and Process Skills (AMPS):

The AMPS ( measures a person's performance capacity for activities of daily living (ADL) and/or independent living.

 for more information: https://www.jrrehab.ca

A self-administered functional assessment for a patient seen in primary care. It provides information on the patient's physical, psychological, social and role functions. It can be used both to screen initially for problems and to monitor the patient over time.

  • Sections: (1) physical function in the activities of daily living, (2) psychological function, (3) role function, (4) social function, (5) variety of performance measures

15 min to administer

For fall risk assessment

 

For more info: 

website Fall Risk Assessment: MedlinePlus Medical Test 

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Falls Risk Assessment Tool (FRAT):

A 4-item falls-risk screening tool for sub-acute and residential care, which includes three sections:

  • Part 1 - falls risk status.

  • Part 2 – risk factor checklist.

  • Part 3 – action plan

for more information: https://www.physio-pedia.com

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MORSE Fall Scale (MFS)

A rapid and simple method of assessing a patient's likelihood of falling.

PDF: https://networkofcare.org/library/Morse%20Fall%20Scale.pdf

A short 5-item instrument designed to measure global cognitive judgments of satisfaction with one's life.

The scale usually requires only about one minute of a respondent's time.

Canadian Occupational Performance Measure:

The COPM is a client-centered outcome measure for individuals to identify and prioritize everyday issues that restrict their participation in everyday living. This measure focuses on occupational performance in all areas of life, including self-care, leisure and productivity. This outcome measure is used with persons of all ages.

for more information: https://www.thecopm.ca/

Home visit assessment (Checklist): ​

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Before doing an actual driving test, we test:

  • Cognitive skills (might use MOCA, MMSE, etc.),

  • Physical abilities (like ROM, MMT, etc.)

  • Transfer (functional skills)

Techniques and environmental adaptations:

“to increase safety”

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As part of the normal development of a person, some functions deteriorate, such as vision, hearing, immunity, memory, attention and others, which affects the individual functioning of daily activities and this may make them tense, angry or even embarrassed. Therefore, the occupational therapist provides the appropriate treatment for these natural deteriorations, by training specific skills, modifying the environment, and suggesting some aids.

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Some techniques can be used, such as:

  • Blind cane, assistive animal, adaptive markings (such as contract paint or tactile skid strips)

  • Magnification

    • Stand magnifiers, Hand-held magnifiers, Telescopes or a monocular, Neck wrap magnifiers, Magnification lamps

                  =>

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Note: Educate the client on limitation of the device (Restrictions of field of view, Maximum size of magnification)

 

  • Lightning

Should be appropriate, sufficient, even, adjustable, sustainable, simple, and adaptable.

  • Lighting fixtures

Table lamps, Floor lamps, Gooseneck lamps, Under counter lighting, Disk Lights, Automatic night lights => 

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This is important for reading, performing ADL’s, navigating in the house and fall prevention.

 

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  • Writing

    • Teach the client the PBS technique

    • (Print, Block Letters, Space it out)

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  • Reading

    • Big size font, easy to read font and magnifiers

 

  • Sensory substitutions

An alternative to devices, and clients can utilize their sense of touch or hearing to compensate for vision loss.

  • Liquid level indicator, Bump dots, Tactile Paint, Beads of safety pins to identify clothing, Talking devices, long cane and braille

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  • Eccentric Viewing:

The eccentric viewing technique involves focusing the central vision or blurred area on a different portion of the object or words to allow the client to use their peripheral vision to read.

Note:  Eccentric viewing does not change or improve vision; rather, it is a technique that can benefit clients in their everyday life

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Steps:

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  1. Instruct the client to look at the center of the target and without moving his/her eyes locate the area of the clock that was blurry/distorted before.

  2. Instruct the client to look above the card to see if the clock becomes more complete and clearer.

  3. You can cue the client by moving your and in the direction, you want them to look.

  4. Repeat with moving the eyes above/below and left /right of the image to find the best location to complete the image.

  5. When the PRL[1] is located explain to the client what this area is and how it will be used for task completion.

 

  • Contrast

    • Specially for walls, sidewalks and stairways may not be marked

    • They might not see water on the floor

 

  • Organization (reduce clutter)

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Technique for low vision and hearing: when someone calls his picture shows

 

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[1] Preferred Retinal Locus (PRL) is the site of the best vision when the fovea is damaged.

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There are limited information and resources available regarding occupational therapy’s role in addressing the functional connection with hearing loss in older adults.

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  • Compensatory Strategies

    • lipreading, auditory-visual training, stress management, and assertiveness training[1]

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  • Communication strategies (for caregivers)

    • Using physical gestures and facial expressions to assist communication

    • Facing the individual and maintaining eye contact to enable lip reading

    • Adding longer and more frequent pauses during conversation are all simple yet helpful changes a person can use to improve understanding

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  • Devices =>

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Technique for low vision and hearing: when someone calls his picture shows

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[1] form of behavior therapy designed to help people stand up for themselves

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Cognitive skills:

  • Memory techniques

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Mental functions:

  • Depression and anxiety 

  • Breathing/ relaxation techniques: 

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For more information:  Stress Management: Doing Progressive Muscle Relaxation | Michigan Medicine (uofmhealth.org) 

  • Educate them about the importance and benefits of sport/exercise

  • Energy conservation techniques

  • Lifestyle Modifications

    • A graded program of increased activity and participation in occupation, Stretching, Strengthening, aerobic activity, guidelines for monitoring HR, BP, and rate of perceived exertion, environmental factors.

  • Education regarding typical bladder physiology and pathology

  • Bladder diary analyses to determine current frequency and severity of symptoms

  • Bladder retraining and fluid titration based on findings of bladder diary

  • Modifications to food and fluid intake to reduce exposure to irritants

  • Manual pelvic exam to assess muscle strength and coordination

  • Training in a pelvic floor home exercise program to improve muscle strength and coordination

  • Relaxation techniques to reduce sympathetic activation and risk of urge incontinence.

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Techniques to support the participants’ integration of training into their existing habits and routines:

  • Utilization of education, occupational self-analysis, and problem-solving techniques, which results in action planning and goal setting

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Intermittent Clean Catheterization PDF prepared by Mr. Mohammad Sbihat

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Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813499/

 

For more information:  

https://www.medbridgeeducation.com/blog/2018/04/addressing-incontinence-home-ots-guide/

Feeding, hygiene, grooming, dressing, toileting, bathing, and mobility

It also includes medication management and recreational activities

Assistive tools => click here to go to Assistive tool page 

Elderly finds it hard to sleep or they wake up frequently during the night.

 

Role of OT in rest and sleep includes:

  1. Screening and evaluation

  2. Treatment and intervention

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Key areas to address while evaluation:

  1. Sleep preparation and participation

  2. Sleep latency (how long it takes to fall asleep)

  3. Sleep duration (how many hours of sleep)

  4. Sleep maintenance

  5. Day time sleeping

  6. Pain during sleep

  7. Physiological status

  8. Emotional status

 

Interventions:

Non-pharmaceutical techniques include:

  • Developing good sleep hygiene (scheduling, adequate sleep routine, adequate amount, etc.)

  • Getting up and doing the quiet activity if unable to fall asleep within 15-35 minutes

  • Sleep restriction (gradual building up of the healthy amount of sleep)

  • Cognitive strategies and education to enhance sleep (changing beliefs and stressful thoughts)

  • Avoid participating in stressful activity before bedtime

  • Relaxation training (Thinking relaxation thought, muscle relaxation techniques, and massage)

  • Regular mealtime and avoid caffeine in the evening

  • Exercises should be avoided the 2-3 hours before bedtime

  • Rhythmical vestibular input is calming and enhancing sleep

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Environmental adaptation techniques include:

  • Comfortable bed (height, width, etc)

  • Ensure the comfort of the mattress

  • Ensure the comfort of the pillow

  • The texture of the sheet and weight of the blanket should be addressed

  • The temperature of the environment should be right

  • For sleep, the room should be completely dark

  • Earplug can be used to block proximal noises

  • Relaxation music can be used but on a timer

  • Sleep baskets can be used to enhance sleep in institutional settings

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Safety measures for the elderly:

  • Lock doors

  • Use safety systems like: Cameras or SOS

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We have a role in community-based practice in IADLs, work, leisure and volunteering 

Driving is very important IADL activity that is part of community mobility. A driver needs license and many cognitive and physical abilities.

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Occupational therapist first assesses the person’s abilities to see if he is applicable for driving or he needs some modifications or assistive technologies. As he might have issues like delayed response or low vision due to normal aging and so he needs compensation. on the other hand, he might be a CVA patient or fracture and he lost his abilities and needs full assessment and retraining of skills.

 

Then the therapist can decide whether to give the permission or not (we decide if eligible or not). If not, occupational therapists help older adults’ transition from driver to rider with the emphasis on the mobility the driving provides, preserving social engagement and an active lifestyle.

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Impairments and functional limitations might include

  • Impaired physical function, Vision loss, Perceptual impairment, Cognitive impairment, or Medication side effects (sedation, hypoglycemia, blurred vision, hypotension, dizziness, syncope or loss of coordination)

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Article:

The Impact of Driving Cessation on Older Kuwaiti Adults: Implications to Occupational Therapy 

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link:https://www.researchgate.net/publication/263514775_The_Impact_of_Driving_Cessation_on_Older_Kuwaiti_Adults_Implications_to_Occupational_Therapy

PDF: 

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Occupational Therapy Intervention: mainly strategies, adaptive devices, or car modification

  1. Treat underlying limitations to safety and independence:

    • Physical (strength, hand function, ROM, coordination, balance, endurance, abnormal tone), sensory (tactile, vision, hearing, vestibular, pain), behavioral, cognition and/or perception.

  2. Train in compensatory strategies:

    • One-handed techniques and low vision compensation.

  3. Train in the use of adaptive equipment and modifications:

    • Simple - key extenders, leveraging devices, swivel seat cushion, seat cushion, leg lifter, steering wheel covers, extendable visors, handy bar, seat belt adapters, car lifts and carrying devices for a wheelchair or a scooter.

    • Complex - (needs to be recommended and trained by a DRS) – hand controls for the brakes and accelerator, pedal extenders, left-foot accelerator pedal, panoramic mirrors, convex mirrors, steering wheel knobs, turn-signal crossovers.

  4. Instruct in task modification – change the task, eliminate part or all of the task or have someone else do part or all of the task such as.

    • Modifying when and how to drive (e.g., only on back roads, during daylight, avoid left-turns, not during rush hour, or bad weather).

    • Exploring alternative transportation options such as rides with family and friends; taxi cabs; para-transit services; public transportation (buses, trains and subways); walking.

  5. Educate the patient about the steps of transfers in and out of a car.

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Some specific cases/ diseases that need this service:

  • Normal: Elderly, low vision

  • Neurodegenerative diseases: Alzheimer pt. (early), Amyotrophic Lateral Sclerosis, Mild Cognitive Impairment (MCI), MS

  • Physical: Amputation of the Lower Extremity, Post-Poliomyelitis Syndrome, Following Heart Attack,

  • Neuro:  Spinal Cord Injury, stroke

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Adapted driving equipment => click here to go to assistive devices  page)

  • Fastening seatbelt; adjusting mirrors and storing mobility devices.

  • Occupational therapists assist older adults to:

    • Recognize and overcome their fears

    • Problem-solve about how to keep from falling while staying active

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*Recommendations often include a combination of interventions that target improving physical abilities to safely perform daily tasks, modifying the home, and changing activity patterns and behaviors.

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  • Occupational therapy assessments and interventions may include:

    • Cognitive skills

    • Balance (functional skills), including Lower limb balance

    • Strengthening exercises

    • Coping with visual loss

    • Medication management techniques or pill organizers

    • Strategies for environmental, behavioral home safety and community safety

    • Suggesting adaptive Equipment

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For more information, check this link:

https://www.aota.org/About-Occupational-Therapy/Professionals/PA/Facts/Fall-Prevention.aspx

It is important in helping family and caregivers, to educate them about:

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  • The importance of meaningful occupations

    • For example, meal preparation may be an important role for an older family member, but the family may feel they are keeping a family member safe by removing the individual’s need to participate in meal preparation.

  • The consequences of eliminating the preferred roles

  • How to support the older adult in maintaining their contribution to the family

  • Some special techniques, strategies, or equipment based on the patient issues

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It is also important to assist caregivers with maintaining a connection to their own life and valued activities separate from caregiving.

The occupational therapist might visit the house of the elder person to evaluate the hazards, ensure the safety of the environment and suggest home modifications such as: 

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  • Bathroom might need grab bars or nonskid mat

  • Kitchen might need modifications to the cabinets or the arrangement of the most used objects/utensils

  • If the elder is a wheelchair user, the OT might suggest a lifter or even changing the arrangement of the sofas in the living room.

  • Breathing techniques mentioned above

  • Some Exercises that improve strength (cardiopulmonary)

  • Memory games

  • ADL participation activities

  • Social participation activities

Note: home program might be specifically for the individual or for his family (for example to educate them to increase social interaction with the elder)

To improve their quality of life, we try to fill their time with purposeful and meaningful activities and social interactions to decrease loneliness, so we might include in their routines:

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  • Outdoor activities or gatherings

  • Relaxation techniques or activities that lead to it

  • Volunteering

  • Handcrafts

  • Group games (with family or friends)

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In order to gain: 

  • Home and community accessibility

  • Performance satisfaction

  • Independence level

  • Support to caregivers

  • Elder to be able to care for others (IADL)

  • https://medilodgeattheshore.com/

  • https://www.thecopm.ca/

  • Occupational therapy toolkit, Cheryl Hall OT

  • Lecture notes of Dr. Shashidhar Rao, Kuwait University (Physical disability course)

  • Lab lecture notes of Mr. Abdulaziz Alshemmeri Kuwait University (Physical disability course)

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