Health Articles

A distinguishing characteristic of geriatric medicine is the simultaneous management of several clinical problems. Often, these problems translate into functional deficits thai have many causes. Older patients with hip fracture may need (o use a walker to reduce stress on the hip joint, but al the same time they may not be able to learn to use it effectively because of cognitive impairment secondary to dementia. Engaging depressed patients in aclivity may be complicated by their decreased vision secondary to macular degeneration or reduced grip strength secondary to osteoarthritis.
Learning is at the core of occupational therapy interventions, and learning may take longer as people age, largely because of the reduced efficiency of the mechanisms that receive, process, and act on information. The extent of these changes is variable, however, and many elderly persons remain highly efficient learners. These normal age-related changes may be compounded by disease-related changes that compromise attention, concentration, memory, problem solving, judgment, and the ability to respond molorically. Therefore, training programs designed to manage task performance dysfunctions must take into account changes in learning capability. In general, older adults learn best when they arc involved in lasks (hat have personal meaning and they can control (he pace of learning. The environment should have adequate ambient and focused lighting and should be free of distracting stimuli. Some elderly persons may have difficulty distinguishing relevant cues from irrelevant ones (eg, distinguishing the start button on a microwave oven from other buttons), so relevant cues should be emphasized orally, visually, or manually. A supportive social environment helps reduce the frustration associated with the struggle to relearn basic skills.
The traditional outcome of rehabilitation is independent functioning; however, in geriatric practice, functional independence may not be feasible. When independence is not possible, patients may be able to achieve a measure of independence that benefits them and their caregivers. For example, physical stress on a caregiver is reduced when patients learn to bear some weight during transfers. Kven when palients remain totally dependent, occupational therapy may result in their becoming more cooperative with caregivers, particularly during ADLs. For example, violent reactions during dressing may be avoided in a patient with dementia if the caregiver provides breakfast beforehand and shows each garment to the patient before putting it on.

The social environment supports the patient’s lask performance needs when caregivers value functional independence and know how lo promote it. Older patients often depend on caregivers to schedule life lasks, provide needed materials, and give appropriate assistance. Thus, caregivers should be involved in the older adult’s program.
If a caregiver is unable to provide care safely and adequately, alternative resources need to he identified. Many caregivers are elderly themselves and lack the energy or strength to cope with a high level of task dysfunction.

These interventions aim to change the physical environment so Ihal it supports task performance needs. Safety needs may be met by removing risks or installing new elements. Also, since both understimulation and overstimulation adversely affect task performance, the amount of auditory, visual, tactile, olfactory, gustatory, vestibular, or social slim-ulation may he changed as appropriate.
Accessibility may be improved by removing or modifying architectural barriers (such as doors, doorjambs, and thresholds), adding ramps, and lowering work surfaces and storage areas. Accommodating a walker may require rearranging furniture. For some patients with mental impairments, signs and pictures indicating the location of rooms and objects may help.

Self-help aids arc typically used lo promote safety or compensate for specific impairments. Some of ihc safely aids mosl commonly used by older patients are canes, rails on the side and back of Ihe bathtub, non-skid mals on the bottom of the bathtub or shower, shower chairs or benches, reachers, and bedside commodes. Extended handles on tools (eg, eating utensils, combs and brushes, and shoehorns) compensate for range-of-motion restrictions. Raised toilet seats and chair leg extenders compensate for diminished leg strength; while tools wilh built-up handles, spring-loaded or electric controls, or grippers accommodate reduced manual strength. Tremors may lessen with the use of weighted lools. and spills may be prevented by using cups with lids and rocker spoons.
For those with sensory impairment, stimuli can be enhanced; for instance, enlarged dials can be added to telephones for Ihose with decreased vision. Or Ihe type of sensory input can be changed: for instance, a telephone ring (auditory signal) can be replaced with a flashing light (visual signal) for the hearing impaired. Memory aids include automatic dialing telephones, medication organizers and reminders, and pockcl devices lhat cue people by beeping or talking al ihe appropriate time. These examples are only some of the self-help aids that occupational therapists prescribe for older patients.

Splints are fabricated to prevenl deformity or promote function. Static hand splints arc applied to maintain the wrist in a neutral position, the fingers in extension, and the thumb in opposition to prevenl flexion deformities. A wrist cock-up splint holds the wrisl in extension but leaves (he fingers free. A fool drop splint helps maintain 90° ankle flexion.

The goal of habit training is to provide the incentive, structure, and endurance needed to develop and sustain an ordered, yet flexible, pal-tern of daily living. The patient learns to organize tasks from beginning to end, link lasks into effective routines, and understand the social norms or expeclations regarding lask performance. Routines provide efficiency, and because they are almost automatic, Ihey minimize (he need for continuous planning. Key elemenls of habit training in occupational therapy include clarifying values to determine task priorities, examining how time is spent, acknowledging maladaptive patterns, exploring and practicing alternative routines, and consolidating new habit structures.
The patient learns to conserve physical and menial energies through training in time management, ergonomic techniques, and stress management. Tasks arc spaced so that labor-intensive ones are distributed over a day or week. Schedules are arranged to provide the best balance of persona] self-care, home management, leisure, and work tasks, approximating the schedule used in the discharge setting. Opportunity is then provided wilhin occupational therapy to try out new routines.
Group activities allow patients to experience many leadership and helper roles and io practice social behaviors. The groups are task oriented and are similar to groups that older patients are likely to encounter in senior centers, day-care centers, nursing homes, and religious and fraternal organizations; they may engage in cooking, discussions of current events, card playing, exercises, music groups, and religious activities. In essence, for patients with habit deficits, the occupational Iherapist designs a socialization experience in which real-life expectations for life tasks are conveyed.

With this type of intervention, a particular activity is pursued for its own sake. Skills may be developed in functional mobility, personal self-care, home management, leisure, or work tasks, as appropriate. The essence of skill acquisition is practicing tasks under controlled, supervised conditions with the task materials and (he movement patterns being selected to promote success. For many patients, putting on a pullover is easier than putting on a cardigan, so training in dressing may begin with Ihe former and progress to the latter. Assistance is given only when needed and only to the exlenl needed as determined by the skill assessment. As the patient improves, assistance is reduced. Skills learned in occupational therapy must be adapted to the home, leisure, or work situation. Thus, patients practice using a variety of training materials, and they continue practicing until they can comfortably integrate Ihe lasks into their daily routines. During therapy, the therapist reinforces the patient’s sense of competence.
Skill acquisition is used when a patient needs adaptive techniques. healthier movement or behavior patienis, or new skills. When impairments cannot be corrected, patients are taught adaptive techniques, which compensate by using the patients’ strengths. Thus, patients wilh paralyzed extremities resulting from a stroke learn to dress (he paralyzed extremities before the nonparalyzed ones and learn to complele bilateral dressing tasks (tying shoes, buttoning buttons) using only one hand. Programs designed (o acquire skill in protecting arthritic joints, promoting proper body mechanics, and developing more effective interpersonal techniques are examples of intcrvenlions involving healthier movement or behavior patterns.

Remediation is accomplished through therapeutic exercise for the
specific type of impairment. For example, fine motor exercises may be used to alleviate incoordination; visual-perceptual exercises, to correct problems in scanning Ihe visual field; memory retraining, to enhance recognition and recall; and assertiveness exercises, to develop skill in expressing needs. Such exercises simply provide a means to an end; thus, developing an interest or proficiency in the activity is not as important as reducing the impairment. For example, because weaving or sewing is a good activity for relearning fine motor skills, patients may weave or sew. even though they have no particular interest in pursuing it as a hobby.
Interventions to reduce an impairment should be used only if a pu-tient’s prognosis indicates lhat improvement can be expected. Memory retraining might be attempted for patienis recovering from a stroke but not for those with dementia.

Activity is inherently therapeutic, and function improves by engaging in purposeful activity. Using purposeful activity as therapy requires the following: The patient and the occupational therapist must be partners in determining and prioritizing intervention goals and in selecting therapeutic tasks; tasks used as therapy must be meaningful to the patienl; tasks used as therapy must be commensurate with the patient’s ability; and as performance improves, tasks of increasing difficulty must be introduced to stimulate further improvement.

Interventions include therapeutic activity to reduce impairments, acquire skills, and acquire habits; the use of splints and assistive devices; and environmental and social adaptations.