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Case Studies In Gerontology

For The Applied Heath Sciences

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Case Scenarios

Case Scenario 7 - Mrs. Gladys Robinson

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Cross-Discipline Learning Objectives Discipline-Specific Learning Objectives
Occupational Therapy Physical Therapy
References  

 

Mrs. Gladys Robinson, a 79-year-old separated woman, is on the rehabilitation unit of a Saskatoon acute care hospital. She is nearing discharge.

She was admitted September 8th via the emergency room after suffering a fall. She had sustained a fracture of her right dominant humerus and suffered bruising. In the emergency room she was reluctant to discuss how she fell and she also refused to answer questions about her family or her medical history. She did show evidence of significant recent alcohol intake. She was admitted to acute care and underwent internal fixation of the fracture.

After 3 days in acute care, she was transferred to a rehabilitation unit. Further medical information now available from her family physician's records indicated a long-standing history of depression, for which Mrs. Robinson was on medication (Prozac), hypothyroidism (treated with Levothyroxin), and suspected alcohol abuse. The social worker for Mrs. Robinson's case had discovered that her husband had left some 20 years previously. The social worker also reported that Mrs. Robinson has a 44-year-old son with schizophrenia. Mrs. Robinson and her son have had periodic involvement with various municipal social service agencies over the past fifteen years.

Questions arose about whether Mrs. Robinson fell perhaps under the influence of alcohol or whether she was pushed by her son. There are reports of suspicious bruising in the past. Questions also have arisen about her current cognitive status because she is such a poor informant and her information is inconsistent sometimes. Staff could not tell whether she could or would not provide information. She is bitter about her son's illness and was angry when questioned about it.

Mrs. Robinson has a grade 9 education and has never worked outside the home. She and her son live together in a run down, two-storey home that she owns. The bathroom and bedrooms are on the second floor; the laundry facilities are in the basement.
She received welfare benefits prior to the age of 65 and now receives old age security and a supplement; her son receives a disability pension. Apparently, he earns some money "under the table" as a night-time taxi driver during periods when he is mentally capable of doing so.

Mrs. Robinson's only leisure interests seem to be television and movie magazines. Necessities such as groceries and personal care items are usually delivered. She goes to the store or bank only occasionally, usually driven by her son in a borrowed car or his taxi.

Mrs. Robinson's son could not be contacted initially. When he was reached by phone he did not offer any useful information nor did he come to visit his mother in the hospital. The OT built a good relationship with Mrs. Robinson while she was an in-patient. In fact, Mrs. Robinson surrendered the keys to her house so a pre-discharge assessment could be completed.

The OT, after the home visit, reported that the floors were piled high with garbage (newspapers and magazines) and dirty clothing and that the counters, cupboards, and refrigerator contained rotted food and mold/mildew. After listening to this description, the physician suggested that Mrs. Robinson might have Diogenes' Syndrome (Senile Squalor Syndrome).

In addition, four grocery bags full of prescription and over-the-counter medications were collected and brought to the hospital pharmacist for review. Many drugs had long passed the expiry date and several refills of the same prescriptions were apparently in use all at once.

Discharge plans included a referral to Home Care. After hearing the OT home visit report, the case coordinator visited the home as well. She considered the home situation unsafe and stated that Home Care could not provide services until the home was cleaned. She also indicated that such a cleaning job was not within the scope of Home Care services. The team referred this problem to the OT.

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Cross-Discipline Learning Objectives

After completing this case, students should be able to:

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

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

bullet2.gif its benefits,
bullet2.gif its drawbacks,
bullet2.gif the role(s) of the professions within the framework of the model,
bullet2.gif how other team models would function in this case;

bullet.gif Identify the applied health science professions and the other professions (i.e., medical, nursing, social work, neuropsychology, clinical psychology, dietetics, etc.) who (a) might and (b) should be involved on the health care team

bullet.gif Explain the roles (i.e., assessment, therapy/rehabilitation, counselling, discharge planning, etc.) of each of the professions who should be on the team;

bullet.gif Identify areas of mutual concern and propose methods of enhancing cooperation with members of other disciplines, with special attention to the Social Worker and Home Care Coordinator;

bullet.gif Discuss the Home Care Program, its purpose, policies, and services;

bullet.gif Explain the inter-relationship of poverty and mental health and aging;

bullet.gif Discuss elder abuse, including: types and definitions, prevalence, profiles of abused and abusers, contributing factors, services for the abused, and legal responsibility, including confidentiality versus reporting;

bullet.gif Discuss co-dependency and its possible role in this case (between the mother and son);

bullet.gif Identify the symptoms and prognosis of Diogenes'/Senile Squalor Syndrome;

bullet.gif Discuss schizophrenia including causes, prevalence, prognosis, impact on family lifestyle, and options for caring/coping;

bullet.gif Describe the influence of an unreliable historian on medical care;

bullet.gif Identify contributing factors for depression in this case;

bullet.gif Discuss the issue of polypharmacy in the elderly including prevalence, contributing factors, risks, and management strategies;

bullet.gif Discuss alcohol abuse in the elderly including prevalence, prognosis, contributing factors, risks, and management strategies;

bullet.gif Identify a variety of discharge options in this case, and debate the barriers and benefits of each.


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Discipline-Specific Learning Objectives

Occupational Therapy

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

bullet.gif Propose roles for the OT in the assessment and treatment of:

bullet2.gif depression,
bullet2.gif alcohol abuse,
bullet2.gif polypharmacy.

bullet.gif Evaluate alternative discharge plans for this case, including:

bullet2.gif home - community services available/needed,
bullet2.gif placement - levels of care, lifestyles, and eligibility criteria, and
bullet2.gif client competence/capacity to choose.

bullet.gif Describe the OT role with regard to elder abuse.

bullet.gif Describe the occupational performance deficits which OTs should address in this case, and propose intervention methods.

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Physical Therapy

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

bullet.gif Select age-appropriate assessments of functional levels in the physical domains of:

bullet2.gif mobility,
bullet2.gif strength,
bullet2.gif flexibility,
bullet2.gif balance, posture, and sensation,
bullet2.gif pain.

bullet.gif Develop and evaluate prioritized therapeutic strategies consistent with the individual's rehabilitation goals for physical function.

bullet.gif Recommend physical aids as necessary.

bullet.gif Identify communication issues which might influence interactions with the individual or relevant caregivers.

bullet.gif Identify community-based resources for the individual and caregivers.

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References

Bergman, K. (1991). Senile self-neglect (Diogenes' syndrome). In R. Jacoby & C. Oppenheimer (Eds.), Psychiatry in the elderly (pp. 862-863). Oxford: Oxford University Press. {AUD, OT, PT, SLP}

Elder abuse: The hidden crime. (1991). Toronto: Advocacy Centre for the Elderly and Community Legal Education Ontario. {AUD, OT, PT, SLP}

Hobson, S. (1996). Being client-centred when the client is cognitively impaired. Canadian Journal of Occupational Therapy, 63, 133-137. {OT}

Hopson-Waller, S.D. (1990). Substance abuse in older persons with disability: Assessment and treatment. In B. Kemp, K. Brummel-Smith, & J.W. Ramsdell (Eds.), Geriatric rehabilitation (pp.279-293). Boston: College-Hill. {OT}

Iglarsh, Z.A. (1996). Stress and aging. In C.B. Lewis (Ed.), Aging: The health care challenge (pp. 279-304). Philadelphia: Davis. {OT}

Kart, C.S., Dunkle, R.E., & Lockery, S.A. (1994). Self-health care. In B.R. Bonder & M.B. Wagner (Eds.), Functional performance in older adults (pp. 136-147). Philadelphia: Davis. {OT}

Ludwig, F.M. (1991). Cognitive impairment in older adults. In J.M. Kiernat (Ed.), Occupational therapy and the older adult: A clinical manual (pp. 156-174). Gaithersburg, MD: Aspen. {OT}

MacLean, M.J. (1995). Abuse and neglect of older Canadians: Strategies for change. Toronto: Thompson. {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}

Ontario Association of Professional Social Workers. (1992). Elder abuse: A practical handbook for service providers. Toronto: Author. {OT}

Plopper, M. (1990). Evaluation and treatment of depression. In B. Kemp, K. Brummel-Smith, & J.W. Ramsdell (Eds.), Geriatric rehabilitation (pp.253-264). Boston:
College-Hill. {OT}

Rabbins, P.V. (1992). The Diogenes' or senile recluse syndrome. In J.E. Birren, R.B. Sloane, & G.D. Cohen (Eds.), Handbook of mental health and aging (p. 473). San Diego: Academic Press. {AUD, OT, PT, SLP}

Riley, K.P. (1994). Depression. In Functional performance in older adults (pp. 256-268). Philadelphia: Davis. {OT}

Rogers, J.C. (1986). Occupational therapy assessment for older adults with depression: Asking the right questions. Physical and Occupational Therapy in Geriatrics, 5, 13-33. {OT}

Silberfeld, M. (1992). New directions in assessing mental competence. Canadian Family Physician, 38, 2365-2369. {AUD, OT, PT, SLP}

Venesy, B.A. (1994). A clinician's guide to decision making capacity and ethically sound medical decisions. American Journal of Physical Medicine and Rehabilitation, 73, 219-226. {AUD, OT, PT, SLP}

Yee, B.W.K., & Williams, B.J. (1996). Medication management and appropriate substance use for the elderly. In C.B. Lewis (Ed.), Aging: The health care challenge (pp.325-363). Philadelphia: Davis. {OT}

 

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