CHAPTER NINE Case studies in care of the elderly

Jennifer Nitz, Susan Hourigan

Case study 1: Colles’ Fracture from a Fall 304

Case study 2: Bilateral Osteoarthritis in Knees 305

Case study 3: Palliative Care – Working in Community as Part of a Community Palliative Care Team 307

Case study 4: Post-operative Hemicolectomy 309

Case study 5: Nursing Home Resident 311

Introduction

A large proportion of adult physiotherapy practice will focus on older people. Consequently, a clear understanding of how ageing affects all body systems and how these changes might affect your assessment, goal setting and treatment is necessary when working with these patients. Older people often present with a number of medical conditions in addition to the current presenting clinical problem and these need to be identified and considered for their effects on the proposed clinical management. This consideration ensures that a safe and maximally effective treatment programme is developed for the patient. Patients are individuals and it is their innate physical, environmental, social and behavioural characteristics that need to be included in the reasoning processes as their physiotherapy programme of treatment is developed.

With the relocation of sub-acute management of patients from institutions to the community, much of one’s practice with older people could be located outside hospitals in day therapy centres, private practice rooms, patients’ homes, retirement villages or aged care facilities (nursing homes). The workload will vary and, to some extent, depend on travel time between patient homes if home visiting or if in one location. In a typical community-based day, it would be expected that one would consult with between 6 and 14 patients individually and also may be involved in conducting group sessions. The physiotherapist also has a role in injury prevention which may involve the training and assessment of staff and carers working in this area. It is important that a working day is structured so that all aspects of work can be accommodated. It is essential to consider travel time between clients and try to schedule visits to minimise distances travelled. It is necessary to develop time-management skills in order to leave time for good documentation of clients’ notes. This includes assessment findings, goals, treatment, appropriate safety warnings, outcome measures appropriate to the individual and their conditions, expected outcomes and planning for patients’ progression to self-management of their condition where possible, and a return to a fulfilling life experience. Other duties may involve communication with older people’s family members, liaison with doctors, pharmacists, nurses and other allied health professionals, and the development of policies and practices related to running facilities and centres which care for older people.

Often, the most important part of physiotherapy practice in this area is directly related to assessing functional abilities, e.g. mobility and the treatment may prioritise aspects that will lead to improved independence and safety in activities of daily living. This may often be treatment related to reducing pain, improving balance or rehabilitation of safe independent or assisted walking abilities.

CASE STUDY 1 Colles’ fracture from a fall

Physiotherapists working in orthopaedic out-patients, fracture clinics or private practice might encounter a patient with the scenario that follows.

Subjective assessment

PC

64-year-old lady who has just had the cast removed after 6/52 of immobilisation for a Colles’ fracture of her right wrist. She has been referred to physiotherapy for exercises

HPC

Patient tripped and fell on an uneven section of pavement while hurrying to the bus stop on her way to work

After application of the cast on the day of injury, patient did not receive any instruction regarding prevention of joint stiffness or swelling before being sent home

She had no problems that she felt were worth reporting during the time of immobilisation

Objective assessment

Observation

A thin, slightly stooped woman

Holding right wrist in left hand in guarded position across her body

Her hand and fingers are swollen and quite pink with scaly and flakey skin

There is a visible deformity/bulge just above the wrist from the fracture callus

Pain

Present when the fracture site is touched and when moving her hand and finger joints. Also in her shoulder when lifting her arm to dress

ROM

Moderately limited from pain and stiffness in the shoulder and from swelling, pain and stiffness in the wrist, hand, thumb and finger joints

Grip strength

Right hand is 25% of her left (right dominant)

Pinch grip strength 40% compared to her left hand

Sensation

Some slight hypersensitivity in the finger and thumb tips

Patient’s goal

To ‘get back to normal’

Questions

1. What underlying factors or conditions would you consider in this situation? How might these affect your physiotherapy management?

2. What should you consider about her functional ability?

3. What information is important to find out about the circumstances of the fall the patient had?

4. Is there any other assessment that you might consider important to undertake with this patient?

5. What should you target in your treatment programme?

6. How frequently would you bring the patient back for treatment?

7. What outcome measures would you use to record progress?

8. What would be your criteria for discharge?

9. Do you think there might be any barriers to continuing exercise or changing lifestyle after discharge?

10. Would you consider referral to other health professionals? If so, what professions might be included?

CASE STUDY 2 Bilateral osteoarthritis in knees

Subjective assessment

PC

72-year-old man presenting with osteoarthritis (OA) in both knees

Causing pain and limiting walking distance to 200 m, then requires rest

VAS score: pain constantly at 4 or 5

Weight-bearing exercise aggravates the pain, but prolonged rest does too

Has consulted you to ‘get rid of his pain’

PMH

Type 2 diabetes and hypertension both controlled by medication

No history of any other medical or surgical conditions

DH

He has been told by his GP not to take non-steroidal anti-inflammatory (NSAID) tablets because they will ‘react’ with his blood pressure pills

Paracetamol only helps the pain ‘a bit’

SH

Retired bank manager

Lives in a low set house with his healthy wife

Their main leisure activities include watching sport and bus tours

He drives a car and receives no community services

Objective examination

Observation

Obese and wears glasses for reading only

Postural alignment – Shows slight varus deformity of the knees bilaterally but nothing else remarkable. Visible wasting of VMO

Swelling – On palpation there is a small effusion in the pre-patellar space bilaterally and general thickening of the knee joint area bilaterally

Skin condition in his legs is good with no evidence of varicose veins or arterial insufficiency

ROM

Knees – 10° lag on the left and 5° lag on the right Flexion limited to 90° on the left and 100° on the right

Passive ROM shows no extension lack and similar flexion range

Accessory movements show no ligamentous or meniscal damage

Patello-femoral joints are stiff

Both hips are limited in abduction and internal rotation range

Ankle and foot ROM are normal for age

Lumbar spine is stiff but retains a normal curve

Muscle strength

Hip abductor, adductor, extensor and rotator muscles are all grade 4 or 4+ on manual muscle testing

Muscle strength around the knee was not tested due to pain inhibition and visible wasting of VMO

Functionality

Has to push up with his arms to assist sit to stand

Uses the support of the railing/banister when ascending or descending stairs

Questions

1. What additional information might you like to find out to assist in your choice of treatment?

2. He mentioned walking is limited to around 200 m before he has to rest and your functional assessment revealed that he uses his upper limbs to assist sit to stand and on stairs. Is there any other aspect related to exercise that you might like to know considering exercise will need to be a large component of his treatment?

3. How will you set your treatment goals to comply with the patients stated goal of ‘getting rid of the pain’?

4. What treatment might you choose to help treat the pain?

5. What exercise modalities might you be considering? Does the presence of a knee lag affect the initial choice of exercise?

6. What self-management strategies will you give to manage his knee OA?

7. What outcome measures would you choose to record progress?

8. Would you consider referral to another health professional to complement his physiotherapy management?

CASE STUDY 3 Palliative care – working in community as part of a community palliative care team

Subjective history

PC

65-year-old lady presents with chest and thoracic pain and fatigue

Pain is constant but varies depending on time of day and activity

Enjoys daily walks which don’t increase fatigue but make her feel ‘a bit puffed’ when walking up hills and occasionally when getting dressed

Worse after washing the dishes when VAS 6/10

At most other times VAS is between 2 and 3

Resting in a supported slightly reclined sitting position helps relieve the pain when most distressing

HPC

History of breast cancer. Had right mastectomy 10 years ago followed by chemotherapy and radiotherapy

Two years ago, she presented with chest pain which was found to be due to metastasis in her T7 vertebral transverse process. There were also hialar lymph node enlargement and two metastases in the right upper lung field

No other medical conditions

DH

Analgesia: oxicodone, naprosin and paracetamol

SH

Moderately active all her life. Played social competition tennis weekly up until 2 years ago

Since then has walked 30 minutes/day

Lives in a two-bedroom flat with her daughter

Objective assessment

Observation

Patient alert, but listless. Medium build

Right arm – lymphoedema apparent (right arm bigger than left with slight swelling in the hand). Patient reports is not troubling her

Thoracic kyphosis that improves when she frequently adjusts her sitting posture

Posture is good in standing or sitting up straight but she needs to be reminded to do this

Respiratory function testing

FCV 2.4 L (expected 3.2 L)

Right upper chest movement is reduced compared to the left

Auscultation – reveals an inspiratory and expiratory wheeze and reduced air entry over the right upper lung field. All other lung fields have normal air entry and no added sounds

Functional assessment

Bed mobility is independent

Rolling to the left causes pain – the lower trunk follows her upper trunk causing considerable torsion to the thoracic spine area

Lying to sitting – rolls to the side and pushes up to the sitting position while simultaneously dropping her legs over the side of the bed. Bed height enables the feet to be on the floor when sitting on the side

Sit to stand – no trouble but uses her arms to assist

Sitting and standing balance are normal

Some shortness of breath on exertion

Questions

1. How is treating a person with a terminal illness towards the end of their life different from other patients you encounter?

2. What comprises your approach to managing this patient’s pain?

3. How will you address the fatigue?

4. What advice will you give the patient about activities she undertakes around the house?

5. Are there any risks associated with her walks that might need to be identified for her so she can increase her awareness and prevent any problems arising?

6. Will you treat the lymphoedema in her right arm? If yes, what management strategies/advice could you give?

7. What advice would you give this patient regarding condition changes she may experience that she should seek assistance to manage?

8. Do you think the patient would benefit from referral to another team member to assist in her care?

CASE STUDY 4 Post-operative hemicolectomy

Subjective assessment

PC

86-year-old lady 1st day post-operative laparoscopic assisted right hemicolectomy

Surgery done under general and spinal anaesthetic with the epidural cannula at T10

Intra-operative blood loss estimated as 1.3 L

HPC

Admitted to hospital 2/7 ago with a suspected bowel obstruction

PMH

Nil of note

DH

Medications are taken for hypertension, left ventricular failure, arthritis and osteoporosis

SH

Lives alone in the community

Home help assists with house work

Visited once weekly by the community nurse (refilled her dosette)

Son lives nearby, visits weekly and her daughter phones on most days

Patient does own shopping with a neighbour and attends senior meetings once a month

Mobilises with wheeled walking frame which helps carry objects and makes her feels ‘safer’

Able to walk about 1 km on the flat with her walking frame at own pace with rests

Vision is good since her cataracts were removed and lenses implanted 10 years ago

Hearing is good for her age

Pre-operative assessment

Drowsy due to analgesics prescribed to control her abdominal pain

Quite lucid and able to answer questions about her home and functional level before admission to hospital

Chest assessment revealed:

Moderate kyphosis

Poor basal air entry bilaterally (likely due to abdominal distention)

Handover from nursing staff

Patient been stable overnight

Complained of pain at rest (VAS 6/10) and on movement (VAS 10/10) in the early hours

Pain team notified, analgesia adjusted with good effect

Current pain VAS 1/10 at rest and 3/10 on movement

Objective assessment

Observation

Naso-gastric tube draining stomach secretions, wound drain and urinary catheter in situ

IV line in her left forearm (KCl⁺ added to normal saline)

Epidural in situ delivering fentanyl and bupivicaine to control her pain

Respiratory

Self ventilating 28% O₂ via face mask

RR 26

SaO₂ 90%

Cardiovascular

HR 72

BP 110/70

Previous 24-hour fluid balance + 2000 mL

Chest assessment

Auscultation – decreased air entry bi-basally and in the right mid-zone with fine end inspiratory crackles bilaterally

Facilitation of air entry only marginally improves basal chest expansion

Supported cough produces 1 plug (5 mL) of thick, yellow sputum

Other information

DVT check is negative

Able to perform circulation exercises well

Patients wound dressing needs changing so you decide to mobilise her later in the morning

When you return at 1100 hours to mobilise her you find she is agitated and unable to follow instructions

Questions

1. What might be contributing to this mild delirium?

2. What do you need to check again even though you did this at 08.30 hours and why?

3. Taking these findings into consideration what is your priority and what treatment could you carry out?

4. Why is it important to liaise with the medical staff in this situation and what further tests or investigations could they carry out to help determine cause of patients behavior?

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