Case Studies
Case PC: PC has multiple chronic diseases including a vascular dementia, diabetes mellitus, type II, with complications including neuropathy, and congestive heart failure. He is also hard of hearing and very impulsive. PC lives with his wife, who also has some cognitive deficits. The OT sees PC regularly to address his pain and works with his wife to provide caregiver training and support as it relates to being a caregiver for someone with dementia. PC scores a 4.2 on the Global Deterioration Scale, indicating a mild dementia. PC is still able to learn new routines with repetition and he benefits from a very consistent routine. He has high anxiety and can become agitated when his routine changes. As part of his chronic disease management for CHF, he knows to weigh himself every morning and he is diligent at reporting his weights to PACE staff. Of concern however, his DM, type II has gotten worse and he now requires a daily insulin injection and to test his blood sugars. Both are new for him and his wife.
Short-term goal (STG): PC will be able to test his blood glucose with minimal assistance within 2 weeks.
PC will be able to record his daily blood glucose with cuing within 2 weeks.
PC will verbalize his new daily routine of monitoring his blood glucose and taking morning insulin within 2 weeks.
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Long-term goal (LTG): PC will be able to monitor and record his blood glucose daily with caregiver assist within 4 weeks.
PC will be able to administer morning insulin with caregiver assist within 4 weeks.
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Frequency: 1-2x/wk x 4 weeks to include sessions with PC, wife, and RN
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Treatment strategies: The OT collaborated with the RN to provide training to PC and his wife caregiver. Knowing that he has a progressive dementia, it is important to include PC as much as possible in managing his own care, but to also include his wife for necessary oversight. It is reasonable that even if PC can be independent today with managing his BG and insulin, he will likely need help in the future. Educational materials were simplified by the OT and were presented multiple times, in multiple ways to increase understanding and carryover of PC and his wife who also has cognitive impairments. Over the course of the first few weeks, the RN and OT determined that the task of managing the insulin was too complicated for PC and his wife and so the task was modified to match their cognitive abilities. The RN decided that pre-filling the syringes would increase the likelihood of taking the insulin correctly, and with training this became an effective modification. The OT and RN both focused on “self-efficacy” and the “perceived benefits” from the Health Belief Model for PC who can become frustrated with his deficits and his complex medical needs.
Case study OJ: OJ has a history of multiple finger amputations and bilateral trans-metatarsal amputations due to complications for DM, Type II and she is primarily w/c bound though can ambulate short distances with assistance and a walker. She has ESRD and is on dialysis. She also has a long history of “noncompliance” and frequent ER visits. She has a diagnosis of vascular dementia and was recently placed in a nursing facility as she was unable to manage at home safely. Some unsafe behaviors that led to this placement included eating under-cooked food, leaving the stove on and almost causing a fire in her apartment, and driving a car into the side of her apartment building. The IDT wanted to address OJ’s “noncompliance”, particularly not wearing her supplemental oxygen, not taking medications as prescribed, and using the ER instead of calling PACE. OJ was notably adherent to attending dialysis 3x/wk. OJ had a neuropsych evaluation a few months prior. The OT completed additional functional cognitive assessments and reviewed the neuropsych results. The OT completed the Montreal Cognitive Assessment and the Brief Cogntiive Rating Scale in addition to assessing participation in ADLs, leisure activities, functional mobility, and IADLs (light meal prep as OJ did voice that she wanted to return home). The following deficits were notable: poor attention and easily distracted by her environment and herself, decreased insight into deficits, low health literacy, decreased language skills including comprehension, poor safety and judgement, and poor short-term and long-term memory. The OT then presented the results to the IDT and provided recommendations regarding how best to communicate with and collaborate with OJ. Recommendations included to relay only one piece of information at time, make sure the environment is distraction free and contextually relevant (e.g. don’t review safe bathroom transfers unless you’re in a bathroom), provide ample repetition, redirection, and simplification, use story-telling to increase understanding and buy-in, and provide positive reinforcement to encourage increased adherence.
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Frequency and duration: as needed for reassessment and collaboration with OJ and IDT.
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Goals: goals were team goals as part of OJ’s plan of care including decreasing avoidable ER use and taking medications as prescribed including wearing supplemental O2
Case LC: LC has a diagnosis of multiple sclerosis, chronic pain from multiple spinal surgeries, recurrent falls, major depressive disorder, and migraines. She has a history of suicidal ideation and substance abuse and is very proud that she has been sober for nearly 15 years. She lives by herself in an accessible apartment with her pet cat, Sassy, and her daughter lives an hour away in a trailer with 4 steps to enter. She uses a rollator when ambulating and is able to drive but does not have a car. LC has some impairment in short-term memory and safety judgement, otherwise is cognitively intact. LC has identified that she would like to “eat better” and she also notes that she doesn’t sleep very well, sometimes only a few hours per night. The OT and PT have been working with LC to address her chronic pain and to establish and maintain a regular exercise routine. Today the OT is looking at improving her nutrition and sleep. The OT and LC create the following goals:
STG: LC will identify at least 3 sleep hygiene techniques to incorporate into her daily routine, within the next 2 sessions.
LC will identify at least 3 strategies to reduce unhealthy eating habits, within the next 4 sessions.
LC will identify at least 3 strategies to introduce healthy eating habits, within the next 4 sessions.
LTG: LC will report an increase of sleep to at least 6 hours per night at least 4 nights per week, within the next 6 weeks.
LC will report incorporating her healthy eating strategies into her daily routine at least 4 days per week, within the next month.
Frequency and duration: OT treatment 2x/wk x 6 weeks
Treatment strategies: Using the Health Belief Model strategies, the OT will look at “perceived barriers”, “cues to action” and “self-efficacy” to facilitate positive changes in health behaviors. LC already has a good understanding of the impact of poor health. The Ecology of Human Performance will be used to determine how the environment can support participation in a given task, namely healthy behaviors as it relates to sleep and eating. One barrier identified is a lack of car and living in an area with no grocery stores. The OT collaborated with home care to assist with grocery shopping and the OT collaborated with the dietician and the participant to come up with a healthy menu and grocery list. The OT also collaborated with the MSW as the participant did not have food stamps and had difficulty affording fresh fruits and vegetables. When looking at sleep, the OT determined that the participant was using electronic devices for many hours late into the evening, was not setting a consistent bed time, and was drinking caffeine in the afternoon. The OT reviewed good sleep hygiene strategies and helped the participant find the ones that would work for her. LC also noted that her mind tends to “run and run” at night. The OT practiced mindfulness strategies with LC to assist with this. The OT also referred the participant back to the primary care provider to determine if there was a medical cause for poor sleep.