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Case Studies In Gerontology

For The Applied Heath Sciences

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Case Scenarios

Case Scenario 8- Mrs. Ruth Simmons


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Medical Information Speech-Language Pathology
Assessment reports Cross-Discipline Learning Objectives
Occupational Therapy Discipline-Specific Learning Objectives
Physical Therapy References - Case Scenario 8

 

Mrs. Ruth Simmons is a right-handed, 65-year-old, English-speaking widow who lives alone in her own home in Charlottetown, PEI. Her house is a two-storey single-family home. The kitchen, living, and powder rooms (i.e., 2 piece bathroom) are on the main floor, the laundry and storage facilities are in the basement, and the bedroom and full bathroom are on the second floor.

Mrs. Simmons drives her own car. She enjoys needlework and reading, and is an active member of a local handicraft guild.

Mrs. Simmons has two adult children. Her daughter, who lives in Manitoba, phones weekly to talk to her mother. Her son lives in Charlottetown, although Mrs. Simmons hears from him once or twice per month.

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Medical Information

Mrs. Simmons called 911 in the early morning hours of May 6th after discovering that she was having difficulty walking and speaking. She was admitted to a primary care hospital on May 6. She was diagnosed with a left anterior occlusive cerebral vascular accident (CVA).

Mrs. Simmons suffers from hypertension and is taking prescribed diuretics. She also is taking hormone replacement medication (i.e., estrogen).

Four days post-admission, the first Stroke-Rehabilitation Team meeting took place to discuss Mrs. Simmons's case. Members of the team included a physiatrist (i.e., medical specialist in rehabilitative medicine), a nurse (who happened to be the randomly assigned case manager), an occupational therapist, a physiotherapist, a speech-language pathologist, a neuropsychologist, a social worker, a dietitian, and a recreation therapist. Team members agreed that multiple assessments of Mrs. Simmons's skills were necessary including those by the speech-language pathologist, the occupational therapist, the physical therapist (all of their reports follow), and the social worker. Additional consults for screening of skills were requested by the case manager for audiology, recreation therapy, podiatry/orthotics (shoe fitting, foot lifts, arch supports, etc.), and neuropsychology.

During the first week post-admission, Mrs.Simmons was assessed fully by the speech-language pathologist, the occupational therapist, the physical therapist, and the audiologist. Their reports follow.

 

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Assessment reports

Audiology | Summary | Recommendations

Audiology

Name: Ruth Simmons Date: May 18

Address: Charlottetown, PEI Age: 65 years

Phone: (902) 661-7896 Physician: Dr. A. Wyle

Mrs. Simmons was referred to the audiology department by the hospital speech-language pathologist following a post-CVA assessment. On May 6th, Mrs. Simmons suffered a left anterior CVA, resulting in right hemiparesis, expressive language problems consistent with Broca's aphasia, and mild receptive language difficulties. Mrs. Simmons' daughter, who lives in Manitoba, was present during the assessment. Previous audiometric results and relevant auditory history have not been obtained from Mrs Simmons' family physician. The daughter reported that her mother has no known hearing problems. Mrs. Simmons speaks with her daughter regularly on the telephone without difficulty.

Pure tone air and bone conduction thresholds were conducted with fair reliability and indicated a mild bilateral sensorineural hearing loss, with further decreased sensitivity in the high frequencies. Speech detection thresholds were obtained with fair reliability and indicated a slight loss of sensitivity. Discriminating testing was not attempted (see audiogram).

Cursory otoscopic examination was essentially unremarkable. Acoustic immittance procedures indicated normal middle ear function bilaterally. Acoustic stapedial reflexes were present at normal levels bilaterally on both ipsi- and contralateral stimulation.

Tone decay measures and acoustic reflex decay measurement were conducted. These tests were negative, suggesting no evidence of eighth nerve pathology.

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Summary

Test results indicate a mild loss of hearing sensitivity bilaterally sufficient to cause communicative difficulty in normal conversational situations and considerable difficulty in noisy or reverberant conditions. These results are consistent with the speech-language pathologist's report of mild receptive problems and reports of communication problems with health care personnel in the hospital.

Recommendations

bullet.gifHealth care personnel and family be advised of communication strategies necessitated by hearing loss.

bullet.gifUse of an assistive listening device such as the 'Pocket Talker' by staff while Mrs. Simmons remains in the hospital,

bullet.gif Return for further assessment in three months.

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Occupational Therapy

ADL | Mobility | Upper Extremity Mobility | Psychosocial Issues | Client Goals | Plan

Mrs. Ruth Simmons suffered a L CVA with R hemiparesis one week ago.

ADL

bullet.gif feeds self independently once tray prepared

no swallowing difficulties noted

bullet.gif washes self independently once set up in chair at bedside, except requires assistance of 1 staff to stand for peri-care

bullet.gif requires assistance for most aspects of dressing; to fasten bra, do buttons, put on and fasten shoes and socks, to stand, to pull up pants

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Mobility

bullet.gif transfers with assist of 1 staff

bullet.gif able to propel wheelchair short distances

bullet.gif ambulates with assistance of a therapist (not on ward as of yet)

bullet.gif sitting balance poor, needs chair with armrests and supervision to reach down to feet

bullet.gif standing balance poor, needs light assistance to ambulate

Upper Extremity Mobility

bullet.gif R hand is swollen, passive flexion of interphalangeal (IP) joints limited

bullet.gif R arm Brunnstrom stage 1

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Psychosocial Issues

bullet.gif becomes frustrated over expressive communication problems

bullet.gif comprehension seems inconsistent

bullet.gif expresses concerns about her health and future

bullet.gif widow with 2 children

bullet.gif speaks with daughter in Manitoba every week or ten days by telephone

bullet.gif calls son weekly, but he is not always in and rarely returns calls, so she speaks with him approximately every two weeks and sees him monthly (invites him to dinner)

bullet.gif has a number of friends and neighbours whom she says she could ask for assistance, but she prefers to be independent or to offer help to others

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Client Goals

1. She wants to return to living alone in 2 storey house (laundry in basement, powder room ground floor, bedroom and full bathroom on second floor).

2. She wants to continue driving.

3. She wishes to continue leisure interest in needlework.

Plan

1. See her 30-45 minutes daily on an individual basis in OT

2. See her twice weekly on the unit in the morning for activities of daily living (ADL) training

 

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Physical Therapy

Mrs. Ruth Simmons was first seen in the acute stage of her illness in the physical therapy setting of the primary care hospital. Assessment of her physical and functional status was completed.

Mrs. Simmons demonstrated significant weakness in the right limb muscles. The upper limb showed flaccidity due to the paresis present - with an inability to resist gravity. The lower limb was not capable of full weight-bearing and there was a flexed knee posture present. For the trunk, strength of forward flexion was impaired.

Balance in upright standing also was impaired with an asymmetrical stance to the non-affected side; the client required a wheelchair for effective mobility. Trunk stability was poor in the anterior/posterior direction.

There was complaint of pain in the right shoulder area. Due to the swollen, flaccid nature of the right upper limb, there was some evidence of developing subluxation of the glenohumeral joint.

Client Goals

1. Use of affected limbs, as much as future muscle tone allows

2. Regain standing balance, and walking ability

3. Reduce shoulder discomfort

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Speech-Language Pathology

Mrs. Simmons was first seen in the acute stage of her illness on May 9th, three days after her admission. She was visited first in her room for a preliminary bedside examination. She was then seen in the speech-language pathologist's office for three, 1.5 hour assessment sessions over the next 3 days.

Standardized and non-standardized speech and language assessment tools were administered to identify the nature of her speech and language problems and to help establish goals for therapy. These included the:

bullet.gif Western Aphasia Battery (Kertesz, 1982)

bullet.gif Revised Token Test (McNeil & Prescott, 1978)

bullet.gif Boston Naming Test (Kaplan, Goodglass, & Weintraub, 1983)

bullet.gif Action Naming Test (Obler & Albert, 1986)

bullet.gif Apraxia Battery for Adults (Dabul, 1979)

bullet.gif Functional Assessment of Communication Skills of Adults (Frattali, Thompson, Holland, Wohl, & Ferketic, 1995)

bullet.gif Bedside speech and language examination (non-standardized)

bullet.gif Oral peripheral examination

The results from the detailed language and speech assessment revealed that Mrs. Simmons exhibited a mild-to-moderate Broca's aphasia, moderate apraxia of speech (i.e., verbal apraxia), and moderate oral apraxia (non-verbal apraxia). Mrs. Simmons's expressive language skills (i.e., spoken and written) were more impaired relative to her mildly impaired receptive language skills (i.e., listening and reading comprehension).

Mrs. Simmons also showed difficulty speaking as a result of her apraxia of speech. She spoke in short, poorly articulated phrases, which contained mostly nouns, verbs, adjectives, and adverbs (i.e., content words). She made several attempts to produce words and phrases correctly, often exhibiting errors in which sounds were substituted, distorted, or omitted on an irregular basis (i.e., paraphasic error). She was frustrated by her inability to say words clearly, as well as by the inconsistency in the accuracy of her speaking.

Client Goals:

1. Mrs. Simmons wants to be able to speak more clearly on a regular basis;

2. Mrs. Simmons wants to be able to use more words in her sentences;

3. Mrs. Simmons wants to use words more accurately in her sentences.

 

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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 a. 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;

2 a. Identify the applied health science professions that (a) might and (b) should be on the health care team;

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

4 a. Identify communication issues which might influence interactions with the individual or relevant caregivers;

5 a . Propose appropriate team liaisons and areas of mutual concern;

6 a. Discuss the components of their clinical practice involving stroke patients with acute care and rehabilitation care staff (e.g., nurse, R.P.N.);

7 a. Describe the prognosis and pattern of recovery of motor speech, language, activities of daily living (ADL), instrumental activities of daily living (IADL), and motor skills (i.e., mobility, etc.) following various types of stroke;

2. Modify their treatment plan depending on the size, and therefore the resources, of the community in which the client lives;

1 b. Describe the effects of a hearing loss on communication especially for stroke patients;

2 b. Describe techniques to modify the patient's environment to accommodate for the client's hearing loss;

3 b. Describe techniques to modify assessment protocols to accommodate the client's hearing loss;

3. Discuss the components of family consultation regarding the effects of stroke and recovery profiles following stroke;

1 c. Explain placement/discharge planning options for stroke patients;

2 c. Describe community support/resource options (e.g., Home Care, support services) for stroke patients.

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Discipline-Specific Learning Objectives

Audiology | Occupational Therapy | Physical Therapy | Speech-Language Pathology

Audiology

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

bullet.gif Alter assessment protocol to tailor to individual client needs and abilities.

bullet.gif Communicate to the patient the nature, impact and strategies for living with a hearing loss.

bullet.gif Communicate to the relevant professionals what is/are the:

1. nature of the hearing loss of the client,

2. effect of the hearing loss on the client's communication ability,

3. possible effects of the hearing loss on previous assessments conducted by other professionals,

4. strategies for improving aural communication (i.e., hearing) in both primary care and home environments.

a)

bullet.gif Discuss patient-specific discharge planning for aural rehabilitation.

 

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Occupational Therapy

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

bullet.gif Propose assessment and treatment methods for basic ADL (feeding, washing, dressing) with particular attention to:

1. hemi-dressing techniques,

2. one-handed assistive devices,

3. hemi-transfers.

a)

bullet.gif Develop and evaluate OT treatment plans for the motor sequelae of CVA, considering:

1. Brunnstrom stages of motor recovery,

2. Motor Relearning Program (MRP) and (neurodevelopmental treatment) NDT approaches,

3. protection of the shoulder joint,

4. shoulder-hand syndrome.

bullet.gif Identify potential sensory deficits following CVA and propose assessment methods to quantify these.

Compare compensatory and remedial approaches to address deficits.

bullet.gif Identify assessment and treatment methods for home management skills, with particular attention to:

1. kitchen assessment,

2. one-handed assistive devices.

bullet.gif Design discharge plans that include attention to:

1. home assessment,

2. community transportation,

3. community services available/needed.

bullet.gif Identify resources and methods for driving assessment, as well as the probable barriers to driving and the reasons for assessment.

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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:

1. mobility,

2. strength,

3. flexibility,

4. balance, posture, and sensation,

5. 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 community-based resources for the individual and caregivers.

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Speech-Language Pathology

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

bullet.gif List the conditions under which they would refer a person with aphasia to an audiologist, neuropsychologist, occupational therapist, and physiotherapist.

bullet.gif Describe how the language impairment (i.e., aphasia) and the patient's activities of daily living (ADL) skills are inter-related.

bullet.gif Discuss patient specific discharge planning options for home-based speech-language therapy.

bullet.gif Develop communication strategies for adults who are hearing impaired and suffer from aphasia.

bullet.gif Name and describe the standardized tests and the non-standardized assessment procedures used to examine the language and speech skills of a person with aphasia.

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References - Case Scenario 8

Bobath, B. (1970). Adult hemiplegia: Evaluation and treatment. London: William Heinemann Medical Books. {OT, PT}

Brunnstrom, S. (1970). Movement therapy in hemiplegia: A neurophysiological approach. New York: Harper and Row. {OT, PT}

Brunton, K., & McCullogh, C. (1995). Stroke. In B. Pickles, A. Compton, C. Cott, J. Simpson, & A. Vandervoort (Eds.), Physiotherapy with older adults (pp. 255-277). Toronto: WB Saunders. {PT}

Carr, J.H., & Shepherd, R.B. (1982). A motor relearning programme for stroke. Rockville, MD: Aspen. {OT, PT}

Chapey, R. (1994). Assessment of language disorders in adults. In R. Chapey (Ed.), Language intervention strategies in adult aphasia (pp. 80-120). Baltimore: Williams & Wilkins. {AUD, OT, PT, SLP}

Chapman, S.B. & Ulatowska, H.K. (1991). Aphasia and aging. In D.N. Ripich (Ed.), Handbook of geriatric communication disorders (pp. 241-254). Austin, TX: Pro-Ed. {AUD, OT, PT, SLP}

Cole, B., Finch, E., Gowland, C., & Mayo, N. (1994). Physical rehabilitation outcome measures. Toronto: Canadian Physiotherapy Association. {PT}

Cott, C. (1995). Goal setting. In B. Pickles, A. Compton, C. Cott, J. Simpson, & A. Vandervoort (Eds.), Physiotherapy with older adults (pp. 189-196). Toronto: WB Saunders. {PT}

Davies, P.M. (1985). Steps to follow: A guide to the treatment of adult hemiplegia. Berlin: Springer-Verlag. {OT, PT}

Dubno, J.R., Dirk, D.D., & Morgan, D.E.E. (1982). Effects of mild hearing loss and age on speech recognition in noise. Journal of Acoustical Society of America, 72, 534-535. {AUD}

Eggers, O. (1984). Occupational therapy in the treatment of adult hemiplegia. Rockville, MD: Aspen. {OT}

Ferrandez, A-M., Teasdale, N. (Eds.). (1996). Changes in sensorimotor behaviour in aging. Amsterdam: Elsevier. {PT}

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. {AUD, OT, PT, SLP}

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

Helfer, K.S. (1991). Everyday speech understanding by older listeners. Journal of the Academy of Rehabilitative Audiology, 24, 1-34. {AUD}

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

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

Lafond, D., DeGiovani, R., Joanette, Y., Ponzio, J., & Sarno, M.T. (Eds.). (1993). Living with aphasia: Psychosocial issues. San Diego: Singular Publishing. {AUD, OT, PT, SLP}

Lesner, S.A., & Kricos, P.B. (1995). Audiologic rehabilitation assessment: A holistic approach. In P.B. Kricos, & S.A. Lesner (Eds.), Hearing care for older adults. Newton, MA: Butterworth-Heinemann. {AUD}

Levitt, K. (1995). Neurodevelopmental (Bobath) treatment. In C.A. Trombly (Ed.), Occupational therapy for physical dysfunction (pp. 446-462). Baltimore: Williams & Wilkins. {OT}

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., Clarnette, R.M., Braun, E.A., Eismann, M.R., & Sneiderman, B. (1991). Decision making in the incompetent elderly: "The daughter from California syndrome." Journal of American Geriatrics Society, 39, 396-399.

Pickles, B. & Compton, A. (1995). Physiotherapy with older people: A conceptual framework. In B. Pickles, A. Compton, C. Cott, J. Simpson, & A. Vandervoort (Eds.), Physiotherapy with older adults (pp. 1-18). Toronto: WB Saunders. {PT}

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}

Sabari, J.S. (1995). Carr and Shepard's motor learning programme for individuals with stroke. In C.A. Trombly (Ed.), Occupational therapy for physical dysfunction (pp. 501-509). Baltimore: Williams & Wilkins. {OT}

Shimon, D.A. (1992). Coping with hearing loss and hearing aids. San Diego: Singular. {AUD, OT, PT, SLP}

Trombly, C. (1995). Clinical practice guidelines for post-stroke rehabilitation and occupational therapy practice. American Journal of Occupational Therapy, 49, 711-714. {OT}

Tyler, R.S. & Schum, D.J. (1995). Assistive devices for persons with hearing impairment. Des Moines: Allyn & Bacon. {AUD, OT, PT, SLP}

Währborg, P. (1991). Assessment and management of emotional and psychosocial reactions to brain damage and aphasia. San Diego: Singular Publishing. {AUD, OT, PT, SLP}

 

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