Geriatric occupational therapy

Molly Mika

Introduction

Occupation may be defined as any meaningful and purposeful activity or series of activities in which an individual engages. According to the occupational therapy practice framework of the American Occupational Therapy Association (AOTA), areas of occupation include activities of daily living (eating, dressing, toileting, etc.), instrumental activities of daily living (homemaking, meal preparation, money management, etc.), education, work, play, leisure and social participation (AOTA, 2002). Disease, dysfunction and loss associated with advanced age threaten the older adult’s satisfactory engagement in occupations. Occupational therapy (OT) practitioners, consisting of both occupational therapists and occupational therapy assistants, therapeutically use meaningful and purposeful activities to insure and enhance an individual’s participation in chosen occupations.

OT practitioners serve older adults in various settings, including a variety of inpatient settings such as acute care hospitals, rehabilitation centers, skilled nursing facilities and psychiatric centers. Community-based OT may be provided in outpatient settings, clients’ homes or in adult daycare and senior centers. OT professionals may fulfill the roles of direct service provider, administrator, consultant, educator and researcher.

Occupational therapy assessment

In order to provide effective, efficient therapeutic intervention, occupational therapists conduct a thorough twofold assessment of their clients. The therapist conducts an occupational profile (a client-centered interview) designed to gather pertinent information regarding the individual’s occupational history and preferences, the various contexts in which the client engages in occupation, and the client’s values, beliefs and goals regarding his or her current functional performance (AOTA, 2002).

Additionally, the OT clinician conducts an analysis of the client’s occupational performance (AOTA, 2002). He or she observes the older adult engaging in a valued occupation, such as eating, dressing, moving in bed or preparing a meal, to identify the client’s functional strengths and limitations. The clinician then performs standardized and/or nonstandardized tests to specifically pinpoint impairments, such as decreased strength or decreased ability to initiate a task.

Occupational therapists and the interdisciplinary team members share their assessment findings with one another in order to develop a comprehensive treatment plan. In some settings, such as hospitals and home healthcare, interdisciplinary team members contribute their findings to a joint team evaluation. Using the Functional Independence Measure (FIM) or the Katz Activities of Daily Living Scale in hospitals across the United States of America for example, enables healthcare providers to establish a baseline level of performance for each client and provides all team members with a method of tracking a client’s progress in primary areas of daily functioning (Uniform Data System for Medical Rehabilitation, 1993; The Merck Manual of Geriatrics, 2011). While the FIM tool may be entirely conducted by any treatment team member, occupational therapists are often responsible for completing the self-care and transfers portion of the assessment.

Through joint and discipline-specific evaluation, the occupational therapist and the treatment team members, in collaboration with the older adult, prepare for the client’s discharge either home or to the next level of service.

Occupational therapy intervention

Upon completion of the OT assessment, the OT practitioner begins intervention planning and implementation. Practitioners may employ a combination of interventions, including the therapeutic use of self, the therapeutic use of occupations and activities, education and consultation with either individuals or groups (AOTA, 2002).

Case study

Arlene

Arlene’s physician referred her to home healthcare services including nursing, physical therapy and OT. The physician’s orders for OT included training in activities of daily living, transfers, instrumental activities of daily living (homemaking), increasing left upper extremity active range of motion (ROM) and left upper extremity strengthening.

Arlene, an 83-year-old female, recently fractured her left distal humerus, her dominant extremity, when she fell trying to get to the bathroom one night. While the doctor performed no surgery or casting to Arlene’s left arm, he had immobilized it with a simple sling for 6 weeks. He has removed the sling and has ordered therapeutic services through a home health agency. Arlene has diabetes and experiences atrial fibrillation. Her right middle finger was surgically amputated 12 months ago. Arlene has type II diabetes and undergoes kidney dialysis three times per week.

Occupational profile

Arlene resides in a two-story home with her husband and adult son. Her husband uses compressed oxygen 24 hours per day and her son works full time in a warehouse. Prior to her fall and subsequent left humeral fracture Arlene slept in her bedroom and used the bathroom on the second floor of her home. Arlene currently does not access her second story because she cannot use the single handrail when descending the stairs because of left upper extremity pain and ROM limitations. She sleeps in a rented hospital bed on the first floor. As there is no bathroom on the first floor, Arlene toilets using a portable commode and sponge bathes in the kitchen. She relies on her son to empty the commode and for assistance with bathing and dressing. Arlene reports significant limitations when attempting her favorite occupations, cooking and baking.

Arlene reports that she longs to sleep in her bed upstairs as well as use the second-story bathroom. She also wishes to prepare a simple lunch for herself and her husband without the assistance of her son.

Arlene uses a straight cane when ambulating throughout her home and requires supervision to do so as her compromised endurance and dynamic standing balance put her at risk of future falls.

Analysis of occupational performance

The occupational therapist observed Arlene’s performance in functional mobility (transferring to and from the bed, the commode, a kitchen chair and a reclining chair) and in self-care (item retrieval required for grooming in the kitchen and hand washing). Arlene required minimal assistance (a helper contributed approximately 25% of the effort necessary for Arlene to engage in the tasks) with transfers and moderate assistance (a helper contributed approximately 50% of the effort necessary for Arlene to engage in the tasks) with most self-care tasks. The therapist also assessed Arlene’s left upper extremity status and function, including pain and edema (excess swelling that had accumulated in Arlene’s hand as a result of sustained immobilization and now interfered with her mobility) evaluation, active/passive ROM and muscle strength measurement. Moderate edema of Arlene’s left hand and wrist was noted. She experienced moderate pain during gentle passive ROM of her shoulder and elbow and had significant active and passive ROM and strength limitations throughout her left upper extremity. Additionally, the therapist assessed Arlene’s home in order to make recommendations to insure the client’s safety and to optimize her future occupational performance. The occupational therapist noted obstacles such as clear oxygen tubing strewn on the floor in multiple rooms.