Case Studies In Gerontology

For The Applied Heath Sciences


Case Scenarios

Case Scenario 10 - Mr. Jacob Springfield


Medical Information
Presenting Problem
Cross-Discipline Learning Objectives Discipline-Specific Learning Objectives
References - Case Scenario 11  


Mr. Jacob Springfield is a predominantly right-handed, but ambidextrous, 72-year-old retired television repair technician who ran his own business for 32 years out of a converted garage behind his house in Halifax, Nova Scotia. He has been married for over 47 years to Mrs. May Springfield, who is 68 years old. Mr. Springfield and his wife have 3 adult children. The eldest daughter (aged 45) is a family physician who lives in Yukon Territories. Their other daughter (aged 38) suffers from developmental disabilities and lives in a group home in Halifax. The Springfield's middle child, a son (aged 43), lives in Ontario with his family (wife and 2 young children). He is a mechanical engineer.

Mr. Springfield completed Grade 9 and is self-taught in electronic repairs. Mrs. Springfield completed Grade 12 and one year of Business School. She was once her husband's bookkeeper but now works in the home and acts as a volunteer for local community service agencies. Both Mr. and Mrs. Springfield are native speakers of English. They do not speak any other languages.

The Springfield's live in a two-storey clapboard frame house with three bedrooms. Their yard is not fenced. The house opens directly onto the sidewalk in the front. Mr. Springfield's repair shop behind the house opens onto an alley that runs behind the houses on their street.

Mr. Springfield loves puttering in his repair shop and watching television. He has few other interests. They both drive the family car.

Medical Information

Mr. Springfield has a recent history of angina for which he takes Nitroglycerine tablets sublingually as required. His vision is deteriorating and he wears bifocals, which were prescribed and fitted within the last four months. He suffers from presbycusis, which was identified three years ago in a full audiometric evaluation as a bilateral, mild-moderate

sensorineural hearing loss. He was prescribed a behind-the-ear (BTE) hearing aid for the right ear but does not wear it. Mr. Springfield also suffers from prostate problems, which prevent him from sitting down for long periods of time.


Presenting Problem

Mr. Springfield suffers currently from recent memory problems and confusion, which, according to his wife, have been increasing slowly in severity over the past year or so. Mr. Springfield wanders from his home, now more frequently than ever especially during the late afternoon. He gets lost easily. Mrs. Springfield has been spending more time watching out for her husband because of his increased wandering. She has not yet sought support from any outside agencies.

The presenting problem is that two days ago, while Mr. Springfield was out wandering the downtown core area, he was hit by a car as he was crossing the street. He struck his head quite hard on the pavement. He was not wearing his hearing aid at the time. An ambulance took him to the Victoria Hospital in Halifax where he was seen in the Emergency Department by the attending emergency care physician. Mr. Springfield was admitted to an acute care medical ward for a 24-hour observation period with multiple bruises and a mild concussion. A CT scan was performed to determine the extent of cerebral pathology, if any, as a result of his head injury.

Nursing staff reported that Mr. Springfield was behaving strangely upon admission. This was dismissed as being concussion-related. His wife was contacted (based on personal information that the nursing admitting staff found in his wallet). She arrived shortly after he was admitted to the acute care medical floor. While on the ward overnight, Mr. Springfield showed confusion and engaged in inappropriate behaviour (wandering the halls aimlessly, repeatedly searching through the drawers and closets of other in-patients, urinating in a garbage can, climbing into the wrong bed, etc). When asked by the nursing staff about his behaviours (e.g., 'What are you searching for?'), Mr. Springfield insisted that he wanted to go home but could not find his way there. He accused the nurses of keeping him against his will and kept repeating that he wanted to go home. Nursing staff reported that he was upset emotionally by the unfamiliar environment of the floor and that his associated anxiety and frustration made him quite agitated. Mrs. Springfield reported the next morning that these were strange behaviours indeed but that he had exhibited similar ones at home with her over the past few months.

The next morning, the nursing staff requested a consultation with the

geriatric assessment unit team (GAU) of the Victoria Hospital in Halifax. The GAU sent over a multiskilled worker to complete their standard assessment protocol. The worker's assessment included administering the

a) Functional Independence Measure (FIM),

b) the Geriatric Depression Scale (score: 8/30),

c) Standardized Mini-Mental State Examination (score: 16/30), and

d) Reisberg Global Deterioration Scale (score: Stage 4).

As well, a case history was collected through an interview with Mrs. Springfield. The results of the assessment were reported to her.

The Geriatric Assessment Team's primary problem at present is

Discharge from the acute care ward is imminent. Only 24 hours maximum is allowed due to severe financial cut-backs in funding. Discharge planning therefore, is urgently needed.


Cross-Discipline Learning Objectives

After completing this case, students should be able to:

1. Identify the type of team model that was used in this case;

1. With respect to the model used in this case, discuss:

bullet.gif its benefits,

bullet.gif its drawbacks,

bullet.gif the role(s) of the professions within the framework of the model,

bullet.gif how other team models would function in this case;

1. Describe the roles of the occupational therapist, physiotherapist, speech-language pathologist, audiologist, neuropsychologist, nurse, and social worker (in terms of second-stage assessments) once a preliminary assessment has been completed by the multiskilled worker;

1. Explain what a Geriatric Assessment Team is, which professions and disciplines might be on it, how it functions, and what the implications are for care of the patient;

1. Discuss how to resolve conflicts regarding overlapping function between your profession and the other professions involved in this case;

1. Describe what a multiskilled worker is (their role, including the implications of this type of professional on the care of the patient);

1. Discuss the pros and cons of having a multiskilled worker (e.g., territoriality issues, the issue of trusting someone who was not educated specifically to do audiology, OT, PT, SLP, or cognitive assessments);

1. Describe the assessment and treatment options for Mr. Springfield:

bullet.gif the multiskilled service worker can assess and then refer the patient to the most involved discipline,

bullet.gif the treatment involves a case management approach where the case manager/primary case worker deals with the client and the other professions are only contacted for consultation or if what is required falls outside the case worker's area of expertise;

1. Discuss the issues associated with discharge of the patient in this situation. That is, consider the issues with each of these discharge options:

bullet.gif discharge planning and making arrangements to get a multiskilled worker to make a home visit to assess coping ability at home in a familiar environment;

bullet.gif discharge and no follow up (because his wife does not want it);

bullet.gif discharge him as an outpatient and involve the Geriatric Assessment Team;

bullet.gif discharge and send him to a long-term care facility;

bullet.gif Discuss the primary causes of cognitive decline in older adults.


Discipline-Specific Learning Objectives

Audiology | Occupational Therapy | Speech-Language Pathology



After completing this case, audiology students should be able to:

bullet.gif Assess the case and suggest strategies for increasing hearing aid use.

bullet.gif Communicate these strategies to the patient and family, Geriatric Assessment Unit (GAU), team members, and the multiskilled worker.

bullet.gif Interpret the dementia test results and modify the aural rehabilitation program to accommodate the cognitive deficit(s).



Occupational Therapy

After completing this case, OT students will be able to:


bullet.gif Explain the relationship between cognition and occupational competence.

bullet.gif Develop discharge plans:

1. placement - when is it time?

2. community services available/needed,

3. levels of care, lifestyle, cost, and eligibility requirements for each.


bullet.gif Describe the role of the OT in the management of dementia, including;

1. behaviour management,

2. environmental adaptation,

3. cognitive stimulation.

bullet.gif Discuss the issue of caregiver burden including:

1. caregiver depression,

2. strategies to alleviate burden,

3. the role of the OT.


Speech-Language Pathology

After completing this case, SLP students should be able to:


bullet.gif Describe and explain the details of standardized and non-standardized language and communication assessment protocols for patients with suspected dementia.

bullet.gif Develop a communication enhancement programme for the hospital staff and the patient's wife and family.


References - Case Scenario 10

Abrahamson, J. (1995). Effective and relevant programming. In P.B. Kricos, & S.A. Lesner (Eds.), Hearing care for older adults. Newton, MA: Butterworth-Heinemann. {AUD}

At home with Alzheimer's disease: Useful adaptations to the home environment. (1990). Ottawa: Canada Mortgage and Housing Corporation. {OT}

Bayles, K.A., & Tomoeda, C.K. (1993). The ABCs of dementia. Tucson, AZ:

Canyonlands. {AUD, OT, PT, SLP}

Berila, R.A. (1994). Management decisions made by caregiver spouses of persons with Alzheimer's disease. American Journal of Occupational Therapy, 48, 38-45. {OT}

Burke, W.J., Houston, M.J., Boust, S.J., & Roccaforte, W.H. (1989). Use of the Geriatric Depression Scale in dementia of the Alzheimer type. Journal of the American Geriatrics Society, 37, 856-860. {AUD, OT, PT, SLP}

Dellman-Jenkins, M., Hofer, K.V., & Chebra, J. (1992). Eldercare in the 1990's: Challenges and supports for educating families. Educational Gerontology, 18, 775-784. {AUD, OT, PT, SLP}

Fire, K.M. (1995). Interventions with the elderly. In L.G. Wall (Ed.), Hearing for the speech-language pathologist and health care professional (pp. 373-400). Boston: Butterworth-Heinemann. {OT, PT, SLP}

Gillins, L. (1990). Yielding to age: When the elderly can no longer drive. Journal of Gerontological Nursing, 16(11), 12-15. {OT}

Gordon-Salant, S. (1996). Special issue on aging. Journal of the American Academy of Audiology, 7, 141-218. {AUD}

Guidebook for care. (1993). Toronto, ON: The Alzheimer Society of Canada. {AUD, OT, PT, SLP}

Guidelines for care. (1992). Toronto, ON: The Alzheimer Society of Canada. {AUD, OT, PT, SLP}

Hasselkus, B.R. (1989). The meaning of daily activity in family caregiving for the elderly. American Journal of Occupational Therapy, 43, 649-656. {OT}

Hellen, C.R. (1992). Alzheimer's disease: Activity-focused care. Boston: Andover Medical. {OT}

Herbst, K.G., & Humphrey, C. (1996). Hearing impairment and mental state in the elderly living at home. British Medical Journal, 281, 903-905. {AUD, OT, PT, SLP}

Herbst, K.G., Meredith, R., & Stephens, S.D.G. (1996). Implications of hearing impairment for elderly people in London and Wales. Acta Otolaryngologica, Suppl. 476, 209-214. {AUD, SLP}

Holmes, A.E. (1995). Hearing aids and the older adult. In P.B. Kricos, & S.A. Lesner (Eds.), Hearing care for older adults. Newton, MA: Butterworth-Heinemann. {AUD}

How to choose the right place: A guide to services and facilities for older people in Ontario. (1991). Toronto, ON: Ministry of Citizenship. {AUD, OT, PT, SLP}

Hull, R.H. (1995). The effects of hearing impairment on older adults. Chapter 3 of Hearing in Aging. San Diego: Singular. {AUD, OT, PT, SLP}

Hull, R.H. (1995). Improving communication for aging adults who are hearing impaired. Chapter 6 of Hearing in Aging. San Diego: Singular. {AUD, OT, PT, SLP}

Jackson, O.L. (1990). Brain function, aging, and dementia. In D.A. Umphred (Ed.), Neurological rehabilitation (pp.661-680). St. Louis, MO: Mosby. {OT, PT}

Jones, D.A., Victor, C.R., & Vetter, N.J. (1996). Hearing difficulty and its psychological implications for the elderly. Journal of Epidemiology and Community Health, 34, 75-78. {AUD, OT, PT, SLP}

Kafonek, S., Ettinger, W.H., Roca, R., Kittner, S., Taylor, N., & German, P.S. (1989). Instruments for screening depression and dementia in a long term care facility. Journal of the American Geriatrics Society, 37, 29-34. {AUD, OT, PT, SLP}

Keith, R.A., Granger, C.V., Hamilton, B.B., & Sherwin, F.S. (1987). The Functional Independence Measure: A new tool for rehabilitation. Advances in Clinical Rehabilitation, 1, 6-18. {AUD, OT, PT, SLP}

Kricos, P.B., & Lesner, S.A. (Eds.). (1996). Hearing care for older adults: Audiologic rehabilitation. Boston: Butterworth-Heinemann. {AUD}

Lubkin, I. (1990). The family caregiver. In I.M. Lubkin (Ed.), Chronic illness: Impact and interventions (pp. 200-217). Boston: Jones and Bartlett. {AUD, OT, PT, SLP}

Maloney, C.C., & Kasper, P.K. (1991). Discharge planning for the geriatric patient. In J.M. Kiernat (Ed.), Occupational therapy and the older adult: A clinical manual (pp.137-154). Gaithersburg, MD: Aspen. {OT}

Molloy, D.W., Cranney, A., Krajewski, A., Lever, J., Orange, J.B., & Davidson,

W. (1992). The family conference in geriatrics. Canadian Family Physician, 38, 585-588. {AUD, OT, PT, SLP}

Molloy, W., Alemayehu, E., & Roberts, R. (1991). Reliability of a Standardized Mini-Mental State Examination compared with the traditional Mini-Mental State Examination. American Journal of Psychiatry, 148, 102-105. {AUD, OT, PT, SLP}

Morris, A., & Hunt, G. (1994). A part of daily life: Alzheimer's caregivers simplify activities and the home [video and resource booklet]. Rockville, MD: American Occupational Therapy Association. {AUD, OT, PT, SLP}

Oakley, F. (1993). Understanding the ABC's of Alzheimer's disease: A guide for caregivers. Rockville, MD: American Occupational Therapy Association. {AUD, OT, PT, SLP}

Orange, J.B., Molloy, D.W., Lever, J., Darzins, P., & Ganesan, C.R. (1994). Alzheimer's disease: Physician-patient communication. Canadian Family Physician, 40, 1160-1168. {AUD, OT, PT, SLP}

Principi, E., Lever, J., Vertesi, A, Molloy, D.W., & Tuttle, I.M. (1996). Use of multiskilled assessors on an interdisciplinary team. Physiotherapy Canada, 48, 127-130. {AUD, OT, PT, SLP}

Raiford, C.A. (1988). Modifications in hearing assessment procedures for the older adult. In B.B. Shadden (Ed.), Communication behavior and aging: A sourcebook for clinicians (pp. 227-236). Baltimore: Williams and Wilkins. {AUD, SLP}

Raiford, C.A. (1988). Treatment for the hearing impaired older individual: A gerontological perspective. In B.B. Shadden (Ed.), Communication behavior and aging: A sourcebook for clinicians (pp. 237-247). Baltimore: Williams and Wilkins. {AUD, SLP}

Reisberg, B., Ferris, S., DeLeon, M., & Crook, J. (1982). The global

deterioration scale for assessment of primary degenerative dementias. American Journal of Psychiatry, 139, 1136-1139.

Schulz, R., & O'Brien, A.T. (1994). Alzheimer's disease caregiving: An overview. Seminars in Speech and Language, 15, 185-193. {AUD, OT, PT, SLP}

Szekais, B. (1991). Treatment approaches for patients with dementing illness. In J.M. Kiernat (Ed.), Occupational therapy and the older adult: A clinical manual (pp. 192-219). Gaithersberg, MD: Aspen. {OT}

Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V., Adey, M., & Leirer, V.O. (1983). Development and screening of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49. {AUD, OT, PT, SLP}

Zgola, J.M. (1987). Doing things: A guide to programming activities for persons with Alzheimer's disease and related disorders. Baltimore: John Hopkins University Press. {OT}


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