Whilst on an outpatient geriatrics assessment clinic, I was referred a patient from Fremantle Hospital for assessment following an extensive hisotry of falls. Each patient is dedicated an hour to so that a comprehensive assessment of strength, ROM, vestibular and motor function can be preformed. The referral stated a history of falls and a solitary social history with bilateral hearing loss. Nothing else was mentioned regarding PMH. Upon viewing the pateint's medical records it was discovered that she had been admitted to hospital on multiple occasions, primarily due to falls in which a fractured NOF and radius had resulted in the past. Her records also stated glaucomas in both eyes and an extensive list of medications that were being taken.
When I called the patient through to the treating room, she displayed great difficulty getting up from the chair and was extremely unsteady ambulating with a walking stick, constantly attempting to grab onto me and any object around her. I remianed close to her but didn't provide any assistance as I was interested to see how she moved. As she approached the doorway, she was unable to negotiate it and asked me to guide her through. It then became clear the extent of her vision problems. As I sat her down to go through a subjective assessment, I realised then how significant her hearing loss was. She did not wear hearing aids therefore I pretty much had to yell. Due to her poor vision she was unable to lip read. What should of taken 10 minutes was taking much longer. There were many inconsistencies in her falls history although it appeared that all her falls were whilst ascending or descending stairs. Her short term memory seemed to be affected also.
I then attempted to follow an objective assessment. This proved to be one of the most chanllenging patients I have ever treated. How do you instruct someone to lift a limb, bend an elbow etc if they can't see what you are demonstrating and they can hardly hear your instruction?! After many futile efforts I discovered that the best thing to do was demontrate the movement by performing the movement on the patient and then asking her to copy it. On occasion this did work. Often when I went to repeat an instruction or question she became flustered and told me not to get angry with her. I assured her that I wasn't but perhaps she noted a tone of frustration in my voice. Eventually I managed to get a Berg Score of 36, extremely poor and reflected the severity of her motor issues.
I tried to become more aware of my tone and how I approached her over the coming weeks and on her 3rd visit she reported that she had fallen the previous day whilst climbing stairs and was unablke to get up for 15 minutes. She admitted that she didn't use her personal alarm pendent and when questioned why she said that she feared she would be taken away and put into a home. I tried to explain to her that that may not necessarily the case however she only became argumentative. After this incident I attempted to focus on stair use and how to use stairs safely with a walking stick. This proved futile as her memory loss prevented any gains. She kept saying that she was trying but wouldn't do any practice or make an effort to improve. It almost seemed like she had lost her will to even function any more.I felt really dishearted that after weeks of exercise trying to get her to help herself no progress was being made.
After 5 weeks my superving physio stated that she had been through the system before and all allied health professionals had tried to help her to no avail. I really felt like something should have been done. Clearly she was not safe to live at home alone and needed to be in full time care but you cannot force someone into care. My physio reassured me that I couldn't have done any more and deliberately didn't tell me to see how I would handle the situation. I was glad that I was given the challenge but can't help but feel that she the health system had failed her.
3 comments:
Good job trying so hard with her, sounds like you tried heaps of different tactics. On my gero placement I had a similar patient and I too found it disheartening that more couldnt be done for them.
I think that even though she wasnt willing to do anything at home, at least she would have received some benefits from the exercises you managed to do with her. Perhaps as time goes by she will see the benefits of extra care (especially if her condition deteriorates)and be able to make use of the community services available.
That was what I found on geri placement as well. There is a limit to how much you can treat their impairments but the focus instead is on modifying their activities of maybe look at provinding aids or services to help them.
It took a while to get around that idea because being new practitioners, we might have the thought that we can start treating everyone. Yet, these requirments and standards have to be adjusted depending on the population that we are treating.
Recalling my experiences like this makes me remember why I obtain the best history from the notes I can (ordering in old ones if necessary). Now when a pt comes to me in so poor a condition I look at what has been done in the past (how could they be in this poor a condition and not received services previously) and consider what else I could do, in the light of what hasn't previously worked. This is the sort of pt that I discuss treatment options with colleagues in case I've not considered something or haven't heard of a new service and they have.
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