Care of the Elderly

University Degree Subjects allied to Medicine

Case Study 1 – Mrs. Adam.

Part 1.

Ageing is a natural process that occurs in the course of an individual’s life. As we age, our bodies change in many ways that affect function and efficiency. These changes occur little by little and progress inevitably over time. The rate of this progression can be very different from person to person (Perring 2007). Aging is an important part of all human societies reflecting the biological changes that occur, but also psychological and social implications (Marr & Kershaw 1998). Death of a partner or child, loss or change of a job, financial crises and major illness are changes that many individuals will experience. Mrs. Adam being 84 years of age has certainly experienced and encountered many of these changes. This essay will follow up on some different factors that have contributed to certain changes in her life.

This case study presents Mrs. Adam, who was recently admitted to the assessment ward of the Department of Medicine for Older People. From the information provided, one can see that Mrs. Adam is a candidate for falls rehabilitation, due to her history of numerous accidents over the last few months. Falls are defined as ‘events that cause subjects to fall to the ground against their will’ and are serious problems among the elderly (Marr & Kershaw 1998). Major injuries can be sustained after a fall, which may lead to hospital admission. How ever minor injuries, like bruising, endured by older people may force them to bed rest which can have serious consequences. These recent falls that Mrs. Adam has had have resulted in bruising, particularly over the hips and consequently led to her referral to the hospital. As mentioned before, our bodies change as we age in many ways that affect the function of both individual cells and organ systems. Musculoskeletal changes lead to decline in bone density, muscle cells and size, quality and strength, leading to impairment of motor function. This can lead to greater risk of falling (McDonald 2004). Conditions like stroke, dementia, osteoporosis and low blood pressure, which are common in older people, can cause weak muscles, dizziness and confusion that increase the risk of falling (NHS 2007). In addition some medicines can cause dizziness, balance problems, confusion or sleepiness, which also increase the risk of a fall. Interactions between medicines can also cause these symptoms as research shows that those on four or more medicines are at greater risk of having a fall. It is quite common for elderly people to be on four or more medications (NHS 2007).

From the case study we are told that Mrs. Adam, up until the recent admittance to hospital, had been living alone, independently in an upstairs flat. We are not told for how long she has been on her own, as there is no mention of previous husband or partner, so there is an uncertainty of background details and circumstances. The only family member that is acknowledged is that of a daughter, who lives on the same street as Mrs. Adam. The fact that she lives so close, we can assume that all the help Mrs. Adam needed previously was on her doorstep, which would have been of real comfort to her. We are informed that she has visited her mother every day since being admitted to hospital.

Mrs. Adam appears to have been a very independent woman, and up until her recent fall was a very active woman. Her interest in socializing and meeting people is evident from the outline of the case study. She is an active member of the church. From this information, one can presume that before admittance to hospital, she attended church on a regular basis. This not only gives her a sense of pride, carrying out her religious duty, but it allows her to interact with others in the community. The need to communicate and interact with others is an essential human drive for all individuals (Marr and Kershaw 1998). She is also a keen member of the Scottish Women’s Rural Institute, (SWRI). These are groups of women who meet together in centres throughout Scotland. The meetings give the opportunity to meet other members, organize events or simply enjoy the friendship of fellow members at the monthly meeting (S.W.R.I. 2007). These meetings give Mrs. Adam something to look forward to. Very often, as people get older their social circle diminishes, through death, decrease in social events and most of all, restriction in activity. It states in Marr & Kershaw (1998), that elderly people living in situations in which they are confined to their own homes and deprived of social contact, can induce loss of self esteem, loneliness leading to lack of motivation and interest in life. These social gatherings in her timetable seem to bring a little light into her daily routine, give her something to look forward.

This is a preview of the whole essay

The move to hospital seems to have greatly affected Mrs. Adam. While living alone in her flat, she was used to being independent and following her own personal devised routine. Being in hospital has forced her into following someone else’s routine, complying with new rules and regulations. She is told when to eat, given a particular time for washing and she may only have visitors between certain hours According to Marr and Kershaw (1998) relocation of an elderly person to unfamiliar surroundings can have adverse effects, delaying recovery of the patient, while in severe cases, may lead to severe depression and hasten death. The new surroundings and routine, along side the new course of medication can lead to state of confusion, lack of interest and motivation in personal self care and life in general. One must also consider her fear of never returning back home. This fear may have some negative psychological effects on her.

The current concern is the safety of Mrs. Adam, due to her history of falls over the past couple of months. Falling among elderly people is recognised as a serious problem for the health services as well as for the elderly people’s welfare (Simpson et al 1998). There are no details of the previous falls however one can assume that her accident of late, has raised much concern as to her health status as she has now been admitted to hospital. She does live alone so there is a high possibility that she may have been lying on her own for some time before she was found. This ordeal can be a very fearful experience for any one, especially the elderly. Clinical experience and previous research shows that older people who are at risk of falling, can become anxious at the thought of being incapacitated on the floor (Simpson et al 1998). Many live in the fear of falling again, and this can lead to loss of confidence. Individuals who have experienced a fall, tend to reduce movements which can lead to a decline in their activities, for fear that a re-occurrence might leave them in a worse situation (Marr & Kershaw 1998). It appears that Mrs. Adam has become isolated since her onset of falls, and is now less active. With the sudden decline in her health over the last few months, the issue will arise as to where Mrs. Adam shall live, keeping her welfare in mind. Considering the multiple falls and her current state of health, a decision will inevitably be made as to whether she should be moved permanently from her flat to a care home or be issued with a care package at home.

Control over one’s activities in the home, assists older people to retain control over their lives and to remain independent. Losing one’s independence is a state with which it can be extremely difficult to come to terms with (Marr & Kershaw 1998). Mrs. Adam could well be faced with this problem in the very near future. Hopes for her returning home and living as she once did do not seem possible. Her health has declined a considerable amount in a very short space of time. Only 3 months ago she was living independently. Her general mobility is decreasing rapidly. The history of falls is a problem that has to be dealt with and addressed immediately. The extent of those numerous falls is unknown to us, but the fact that it has happened in a short space of time gives rise to a lot of concern. The fact that she is having difficulty with mobility in the hospital raises serious doubts as to her capability to look after herself at home.

Mrs. Adam has numerous problems that have led her to her hospital referral. This move has been a terrifying experience for her. Rehabilitation is paramount for her recovery. Collaboration and co-ordination of both the patient and the professional teams will be a key factor in achieving a successful recovery.

Part 2. The role of physiotherapist.

Rehabilitation is an on going process that has been described as the restoration of the individual to his or her fullest physical, mental and social capacity. It requires skill, knowledge and expertise from the entire inter-disciplinary team, not just from one individual team member. Shared decision-making and flexible leadership characterizes interdisciplinary teamwork (Patterson et al 2005). Each relevant profession must have an equal say in the process of planning a suitable rehabilitation program. Effective communication among the team members, with the passing on of relevant information to the patient, is essential if successful rehabilitation is to take place. Naturally, insights from one discipline may challenge the assumptions and practices of another but with good communication skills and strong leadership this can be solved in a professional manner (Marr & Kershaw 1998).

Physiotherapy is a healthcare profession concerned with human function and movement, maximising potential (CSP 2007). The physiotherapist plays a very important role in the rehabilitation of Mrs. Adam. The main focus would be placed on functional abilities, and try to resolve functional restrictions that she may have, for example poor mobility that is restricting her in certain activities. As stated in Marr & Kershaw (1998), reduced mobility and function are inevitable with an older person. The physiotherapist must take the mobility and capability of the patient before admission into consideration. Usually patients can give this information but often therapists require corroborating evidence from a third party (Thames 2002). In this case the physiotherapist should liaise with the daughter and other members of the IDT. It states that Mrs. Adam lived independently and led an active lifestyle, prior to her multiple falls. This can be taken into account when devising a suitable treatment plan and goals. The treatment should be based on achieving the functional goals set for the particular patient (Marr & Kershaw 1998).

Education is a crucial aspect in rehabilitation. Education would be included in treatment by all members of the IDT. Mrs Adam, since her arrival to hospital, has become disorientated and appears to have lost motivation, which can soon lead to serious depression. We are not informed as to her mental state previous to admittance, but can assume that in the last three months that her condition has deteriorated. Studies have shown that depression among older people reaches its highest because of physical dysfunction, and low personal control add to personal and status loss (Miller 1999). One must consider her fear of falling again, the new surroundings and her thoughts on never returning home.

Whilst the physiotherapist would concentrate more on physical rehabilitation reassurance and education, the occupational therapist would put more emphasis on advice concerning aids and adaptations to her house, if she was to return home. The dietician may come to talk to Mrs. Adam about her diet and educate her on the importance of proper eating habits, and a social worker may inform her of her options once discharged and advise her on suitable services available to her in her community.

The physiotherapist must conduct an all round examination to determine the main problems and limitations that Mrs. Adam presents. Once the subjective examination has concluded and relevant information gathered, the physical assessment can begin. Objectively the physiotherapist would observe and assess posture, balance, range of movement (ROM), muscle strength (MS) and gait. The physiotherapist may decide to first assess ROM and MS, taking into account any injuries sustained after her multiple falls. Mrs. Adam’s initial condition must also be acknowledged, as her range and strength that may be considered poor by most standards, may be what she considers ‘normal’.

It is important that the assessment focuses on the patient’s functional activities, rather than problematic joints and muscles (Marr & Kershaw 1998). This would include activities such as general movement around the flat like, walking from bedroom to bathroom, transfers on and off the toilet, and ability to climb the stairs. The physiotherapist can work closely with the occupational therapist to achieve these goals.

Mobility is one of the most important aspects of physiologic function as it is essential for maintaining independence, and because serious consequences occur when independence is lost (Miller 1999). It is important for the physiotherapist to assess Mrs. Adam’s mobility status. This should be carried out as part of the functional assessment, as it is poor mobility which results in restriction of functional abilities and activities of daily living. This assessment would include transfers, balance and generalised movement. The physiotherapist would assess her sit to stand and stand to sit technique, noting how long each procedure took. Bed mobility would also be examined, assessing ability to move up and down the bed, turning over and getting in and out of bed. The physiotherapist may need to re-educate Mrs. Adam and alter her technique, in order to allow her to perform these movements in a more functional manner. The physiotherapist could work closely with the occupational therapist in order to achieve this. Whilst the physiotherapist would advise on movement and exercises to improve her functional movements, the occupational therapist would advise on adaptive equipment that would assist Mrs. Adam to achieve these functional movements.

Balance is another factor that will have to be considered, as this may have been a further cause for her numerous falls. This can be assessed sitting and standing, supported and unsupported. The occupational therapist would need to be informed on the outcome of the assessment by the physiotherapist, as they would need the patient to be termed fit enough for kitchen, washing and dressing assessment. As Mrs. Adam has difficulty with these aspects of personal care, and it is important for these functional tasks to be addressed immediately.

Mrs. Adam lives in an upstairs flat. This raises considerable concern if there is a thought that she may be able to return home. The fact that she already has difficulty with general mobility means that this issue in hand must be dealt with, if there is hope of her return. The physiotherapist can work in proximity to the occupational therapist again. The occupational therapist may have made a home visit and assessed the home environment for potential hazards, like loose carpets and cluttered furniture. Also ensuring a safe banister rail is present and adding other adaptive aid’s identified as necessary. The physiotherapist will then need to informed on the outcome of the home assessment, letting him/her know the number of steps on the stairs that Mrs. Adam will need to be able to master and the general state of the flat, incase there are other issues the physiotherapist made need to address.

After initial assessments, the physiotherapist may wish to combine rehabilitation with the occupational therapist whilst they address Mrs. Adam’s personal self care issues. Mrs. Adam’s balance and mobility can be observed during kitchen assessment or dressing practice. The physiotherapist could also observe gait pattern and ability on their way to the bathroom for washing assessment. This can be classed as an informal assessment as the patient is unaware that they are being observed by the physiotherapist and is in their more ‘natural state’.

Once initial assessments have taken place, regular meetings between members of the IDT should occur to discuss patient status and the evolving plan of care. The issue that will be of most concern will be whether she will return home or permanently move to a care home. If Mrs. Adam is to return home, a social worker or care manager will need to assess her flat and enquire on her present state. Communication with the physiotherapist will inform them of her mobility and functional abilities, and the occupational therapist will inform them on self care capabilities. Contact with Mrs. Adam’s daughter will also be essential as his will enable them to arrange a suitable care package for her, depending on how much daughter wishes to be involved in rehabilitation at home. Discharge would depend on the final agreement from all members of the IDT that have been working closely with her in the rehabilitation in hospital.

The possibility of sending Mrs. Adam to a falls prevention class in the community would be very much part of the IDT discussion at these regular meetings. This would be of great benefit to Mrs. Adam. The class would also provide Mrs. Adam with a new social connection and she will get the opportunity to meet with others falls candidates. She will be able to discuss her traumatic experiences with others which could help her over come her fear of falling. Elderly people who have experienced a fall can loose confidence in them selves and reduce their social activities as they live in the fear of falling again (Marr & Kershaw 1998). It will improve her ROM, strength, increase her confidence and educate her on to prevent future falls and avoid all risks.

Rehabilitation could be a long process for Mrs. Adam. Her discharge would depend on her recovery both physically and mentally. It would be hoped that she would return home but with home help. However, after discharge if it was found that she was not coping at home with care, then permanent movement to a care home would be the only option to ensure safety of both her and her carers.

References:

MARR, J. & KERSHAW, B. 1998 Caring for older people. London: Arnold.

MCDONALD, I. 2004 Care of the Elderly-ageing in a nutshell, [online] available from: [Assessed on 29/12/07]

MILLER, C. A. 1999 Nursing Care of Older People, theory and practice. Philadelphia : Lippincott.

NHS DIRECT, 2007. Health encyclopaedia-Falls causes. [online] available from: . [Assess on 29/12/07]

PATTERSON, F. BLAIR, V. CURRIE, A. REID, W. 2005

An investigation into activity levels of older people on a rehabilitation ward: an observational study. Physiotherapy (Vol 91) p 28–34

PERRING, M. 2007 Healthy ageing. [online] available from:

[Assessed 29/12/07]

REECE, A. C. SIMPSON, J. 1996 Preparing Older People to Cope after a Fall. Physiotherapy. (Vol 82, no 4).

SIMPSON, J. A. HARRINGTON, R. MARSH, N. 1998 Guidelines for Managing Falls Among Elderly People. Physiotherapy (vol. 84, no. 4)

SOTTISH WOMEN’S RURAL INSTITUTE 2007 [online] available from; . [Assessed on 28/12/07]

THAMES, A. 2002 Elder Rehabilitation: Core learning objectives for physiotherapy students during clinical placement. Physiotherapy, (Vol 88, no.3) pp 158-166.

THE AGS FOUNDATION FOR HEALTH IN AGING 2005 The ageing process, [online] available from:

. [Assessed on 29/12/07]

THE CHARTERED SOCIETY OF PHYSIOTHERPY 2007 Physiotherapy Explained, [online] available from: [Assessed on 30/12/07]