Chapter 7 E-materials
Case Study 7.1
Background
• Mr L is an 86-year-old man who lives with his wife in a house (3 steps with two rails into the property).
• His wife (82 years old) is the sole carer and assists with personal care, medication and all domestic activities of daily living.
• Mr L goes to a day centre twice a week.
• The bedroom and bathroom are upstairs (stair lift) and he usually gets up at night to pass urine.
• He is mobile with a wheeled frame indoors but sometimes forgets to use it and he has an attendant-propelled wheelchair for outdoor mobility.
History of present condition
• Mr L was admitted to hospital with pyrexia, urinary frequency and incontinence.
• His wife reports that he had been become increasingly confused and had 2 falls in the last week, each time, their neighbour had to help him up from the floor.
• His past medical history includes vascular dementia, osteoarthritis knees, COPD and stroke with residual left-sided weakness.
• His medications include simvastatin, paracetamol, clopidogrel, Ventolin and salbutamol inhalers.
Physiotherapy assessment
• The physiotherapist assessed Mr L the next day.
• He was found to be disorientated to time and place, but was able to follow one-step instructions. On admission Mr L’s AMTS was 3/10.
• He could move his upper limbs through range. There was moderate rigidity on passive movement especially at the elbow and wrist of the left upper limb.
• He was able to move his lower limbs on command, but had residual weakness of the left lower limb especially the hip flexors and quadriceps (grade 4/5 Oxford scale) with reduced range of movement at the left ankle (plantargrade just achieved).
• The physiotherapist noted reduced muscle bulk of the quadriceps bilaterally and degenerative changes in both knees.
• The physiotherapist and a physiotherapy assistant assessed Mr L’s ability to complete bed transfers.
• He was able to transfer from lying to sitting with moderate assistance of 2.
• He appeared to be fearful of moving and required reassurance when rolling.
• He was able to sit unsupported on the edge of the bed.
• On the first attempt to stand using a wheeled frame, Mr L pushed himself backwards and tried to pull up holding on to the frame.
• To make the transfer to the chair safer, the physiotherapist used a rota-stand with the assistance of 2.
• The physiotherapist gave a handover report to the nurse in the bay and documented Mr L’s current functional ability.
• The physiotherapist identified that Mr L was unable to transfer independently (lying to sitting and sit to standing) due to fear of falling and when moving from one position to another. In addition he had generalised weakness precipitated by the acute illness.
• He was at risk of falls due to cognitive impairment with possible delirium, residual left-sided weakness and reduced muscle power in addition to gait and balance impairment.
• The physiotherapist also noted that Mr L had been unable to get up from the floor following his falls.
• When the physiotherapist discussed what Mr L would like to achieve, he stated that he would like to go home. The physiotherapist involved Mr L’s wife in goal setting.
• The physiotherapist helped Mr L to break this goal down into smaller short-term goals. The short-term goal was to be able to transfer consistently with assistance of one in 2 days and to mobilise with a rollator frame 6 metres with assistance of one in 4 days.
• The Elderly Mobility Scale was chosen as an outcome measure (initial score 0/20).
• The physiotherapist referred Mr L to the occupational therapist.
Treatment
• The treatment plan included a combination of daily specific functional transfer practice with the occupational therapist on lying to sitting, sitting to lying and transfers from the bed, chair and toilet.
• The physiotherapist also prescribed balance exercises in standing with bilateral upper limb support and progression to less support.
• Gait re-education was commenced in parallel bars and progressed to mobilising with a wheeled frame with a chair placed in strategic places.
• The physiotherapist arranged treatment sessions with his wife present so that she could see how her husband was progressing.
• The physiotherapist increased the practice sessions by delegating to the physiotherapy assistant and health care assistant in the bay.
• This ensured that mobility practice could take place throughout the day.
• Over the next 3 days, Mr L is more orientated (MTS 7/10) and is able to transfer with supervision and mobilise 5 metres with a wheeled frame and supervision.
• The Elderly Mobility Scale improved to 8/20.
• Stepping practice onto the first step of a set of stairs with bilateral hand rails was added to the treatment plan.
• The nurses reported that Mr L managed to use a urinal bottle independently at night-time.
Outcomes
• The multidisciplinary team met with Mr L and his wife to discuss his progress and to plan for his discharge.
• Mrs L wanted to continue being the sole carer for her husband, but was concerned that Mr L may fall again.
• The options for further assessment and management of falls risk were discussed with Mr L and his wife.
• The multidisciplinary team referred Mr L to the Intermediate Care team for further rehabilitation at home plus a falls clinic appointment.
• The social worker provided information about voluntary agencies that can provide sitting services.
Case Study 7.2
Background
• She lived alone in a first-floor flat, her husband died 10 years ago.
• Mrs Clarke was able to walk around her flat, sometimes holding on to furniture to steady herself.
• She had not been out of the flat on her own since a fall 6 months previously, but was able to go to the supermarket with her daughter occasionally, getting around the supermarket by using a trolley for support.
• Her daughter visited her every day to prepare her evening meal.
• Mrs Clarke drank a small glass of sherry most evenings before her meal.
History of present complaint (HPC)
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