Safety v.s. Independence: The Role for Therapy · • Elastic shoe laces • Front-closing bra •...

5/22/2013

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Safety v.s. Independence: The Role for Therapy

Presented byCoralie “Corky” Glantz OT/L, BCG, FAOTA

Nancy Richman OTR/L, FAOTA

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Regulation• No resident shall be deprived of any rights,

benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of an establishment,..

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Rights

– The right to respect for bodily privacy and dignity at all times, especially during care and treatment

– the right to live in an environment that supports each resident’s dignity, individuality, independence, self determination and choice

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Self-determination and Participation: The Resident Has the Right to

• Exercising rights means that residents have authority and choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules affecting resident conduct and those regulations governing protection of resident's health and safety.

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Increase Function & Quality Of Life

• Intervention must use a client’s strengths in order to offer success and therefore build “self”

• Focus - needs to change from looking at deficits to looking at strengths

• Remove cues of “sick role” to focus on “Quality of Life” in present

• In order to recognize their strengths, we must match their remaining cognitive abilities with activities

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• We need to empower our clients by using what they presently have (don’t worry about tomorrow)

• The caregiver must alter his/her approaches to allow the client to use his/her strengths and to perform at the highest level of his/her capabilities

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• We may need to:– Include cueing and alteration of the environment

in our interventions in order to remove impediments to successful completion of a task.

– Develop compensatory techniques – Address depression

• Provide positive reinforcers of the desired behaviors to help build self-esteem

• Give opportunity to be useful

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Normal Affects of Aging That Can Impair Independence

• Vision:– Difficulty adjusting to light from dark

• Use night lights• Consistent and appropriate furniture placement• Patio doors marked well

– Sensitivity to glare• Shield lights• Avoid shiny floor surfaces• Use appropriate window coverings

–

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• Vision:– Decline in depth perception

• Take care not to misjudge high or low places• Allow your foot to feel the height and depth of a stair

– Need for contrasts and colors• Rug edges contrast floor color• Colored door thresholds • Take care on wet services

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• Hearing:– Decrease in certain tones - need for louder or

lower sounds or visual alerts• phones• door bells• smoke alarms

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• Touch:– Sensitivity to heat, pain and pressure

• Water temperature controlled-heater set below 140 degrees

• Smell:– Decreased olfactory (smell) sense

• Discard food before it spoils• Make sure gas is off - check for leaking gas• Use audible or visual smoke alarms

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• Balance and Gait: – More difficulty to maintain or recover balance– Speed and length of stride altered– Balance and gait affected by:

• Vision• Muscular strength• joint flexibility

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Involvement and Environment

• Includes the human and non human environment

• Environment: the aggregate/combination of surrounding things, conditions, influences

• The less competent an individual is, the more the environment accounts for the individual’s behavior

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OBTAINING MAXIMUM FUNCTIONAL ABILITIES THROUGH

ENVIRONMENTAL MODIFICATIONS

• Ensure safety and security• Support functional ability through meaningful activity• Maximize awareness and orientation• Provide opportunities for stimulation & change• Maximize autonomy and control• Adapt to changing needs• Establish links to the healthy and familiar• Provide opportunities for socialization• Protect the need for privacy

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Suggested Interventions Safety Risks

• Prevention is important• Be more alert to safety risks when person

is rushed, stressed, physically ill, or upset• Remove clutter from hallways, rooms, etc.

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• Be aware of the effects of overmedication or low blood pressure on balance and perception

• Adequate lightening• Practice safety procedures - fire evacuation,

first aid for burns, how to move a person who has fallen, the Heimlich maneuver

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• Special areas or units confine the risk with appropriate locks, monitoring devices, accident-proofing devices

• Identify high risk residents; everyone responsible for these residents’ safety

• Make sure family has considered the Safe Return program

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Suggested Interventions Con’t)Safety Risks

• Check availability of inedible items he/she may swallow or items that resemble actual food

• Never leave the person alone in the shower or bathroom

• Store personal grooming items in locked cabinet

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What is Making the Task Unsafe?

• Can we make the task safer?– Can the task be altered?– Can compensatory tasks or methods be

developed?– Can the environment be altered?– Can the time requirement be lengthened?– Can we add verbal or visual cues?

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Task Matches Abilities

• Do the demands of the activity match the abilities of the person?

• Requirements needed to carryout a task– Objects– Space– Social demands– Sequencing or timing– Required actions– Required underlying body functions – Required body structures

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Analysis of Activity Demands to Match Abilities of the Resident

• Cognitive abilities of the resident– Orientation– Ability to follow directions– Ability to learn– Memory– Judgment/safety– Ability to abstract

• Physical abilities of the resident– Ambulation ability– Coordination– Endurance

• Sitting tolerance– Loss of sensation

• Cognitive demands of the activity– Prior knowledge or training– Recall– Recognition

• Physical demands of the activity– Use of both hands– Fine motor skills– Sitting, standing, strength,

moving – Bending, reaching , stretching,

flexibility– Energy level needed

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Analysis of Activity Demands to Match Abilities of the Resident

• Social strengths of the resident– Interaction with others

• Sensory abilities of the resident– Hearing– Vision– Touch

• Communication– Receptive– Expressive

• Perceptual/sensory

• Social demands of the activity– Done independently– Within a group– Level of interaction

necessary

• Sensory demands of the activity– Adaptations

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To Facilitate the Eating Process

• Assistive devices may make self-feeding possible longer and thus maintain

• Independence• Self-esteem • Caloric intake

• Finger foods, or food placed in pita pockets.• If residents are distressed, consider saving the meal

to reheat at a later time when they might be more receptive

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• Consider drug food interactions -medications may cause nutrient malabsorption or loss of appetite

• Assigned and consistent seating patterns can reduce disorientation

• Small square tables define space and reduce distractions

• Serve beverages in large cups or mugs that are half full

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• Avoid plastic utensils• Avoid styrofoam cups• Serve one food at a time• More finger foods• Boneless foods• Sandwiches• Use honey drizzled over food• If resident refuses to eat because of no money-

tell them the bill has been paid26

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• Can use creamy peanut butter in hot cereal to add protein and calories

• Several small meals may help• Allow wandering• Allow time• Be flexible with serving techniques• Redirect behavior, do not scold• Verbal and tactile cueing

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To Facilitate the Dressing Process

• A slower pace, allow enough time• Offering one item at a time

• Prompt that it is time to complete a task• To keep the client focused

– Avoid delays– Avoid interruptions

• Lay out clothes in sequence• Explain the process one step at a time

– Manageable steps28

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• Keep the process as routine as possible• Don’t be concerned if clothes don’t match,

insisting on redressing can lead to frustration or combativeness

• Cotton clothing may feel more comfortable to the resident, and odors wash out more easily

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• When placing clothing on the bed, be sure there is a color contrast between the clothing and the bedspread so the resident can more easily see the items

• Residents may wish to dress as they used to (e.G., Tie, sport jacket, suit, make-up, jewelry)

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• Make sure there is enough light so the resident can see the clothing

• Make sure the room is warm enough• Eliminate accessories• Have a chair available in case client

looses balance• Offer choice of only two items

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• Clothing a size or two larger may help the resident dress more easily, jogging clothes if appropriate to previous life style

• Consider clothing that is the same on both sides (sweatshirt)

• Consider replacing hooks, snaps, and buttons with Velcro closures

• Slip-on shoes with Velcro closures are good alternatives to lace-up shoes

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• Button hook or button aid• Large easily grasped zipper pulls or rings• Elastic thread to sew buttons onto cuffs• Dressing stick or reacher• Elastic shoe laces• Front-closing bra• Long handled shoe horn and sock donner

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• Slacks and robes should not be too long so they don't get stepped on or caught on something

• Flat shoes with nonskid soles are best for the resident's safety

• Shut room doors and pull down blinds for privacy

• Knee-length stocking only if they have wide elasticized tops – never wear stockings rolled down and secured with a rubber band or garter

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Visual Cues

Solution: Placing clothing in open baskets is better then drawers because the items are more visible. This

wardrobe unit would be even better if the drawers were placed higher. 35

Visual Cues

Solution: Reduce decision making by placing clothing to be worn together on the same hanger.

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To Facilitate the Bathing Process

• Allow residents to do any part of bathing they can/want to; work with the residents and don't always do to or for them

• Use task segmentation to prevent bathing from seeming overwhelming

• Is lighting adequate but not glaring?

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To Facilitate the Bathing Process• Avoid bubble baths and oils

– Slippery– Contributes to vaginal infections– Mineral oil on cloth ok

• Tomato juice added to bath water will help remove persistent odors

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To Facilitate the Toileting Process

• Simplicity in clothing will enable the resident to be more independent with the toileting process– Pull-up sweat pants are easier to remove than

pants with zipper, buckle, and belt.• Keep the bathroom environment as free from

clutter and unsafe items/chemicals as possible

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• Grab bars or riser toilet seats may make getting on or off the toilet much easier for the resident

– However, some residents may become resistive, as these helping devices may not look familiar

• Signs for cueing may be of help (e.g., Men's room)

• Toilet visible, open door

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• If the garbage can is mistaken for the toilet, remove it from the bathroom

• If the sink is used for a urinal, try placing a brightly colored towel over it

• Monitor intake to encourage normal bowel movements– Food– Fluid– Fiber impair

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To Facilitate the Toileting Process• Uphold dignity, do not scold or embarrass residents

who have an accident• Learn the person’s urination and defecation

schedule• Observe behavior for signs of needing toilet

– Agitation– Restlessness– Pulling at clothing

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To Facilitate the Toileting Process• Pay attention to gender• If resident wants to get up too soon, use an

activity or offer a glass of water to keep them on the toilet

• Washable shoes if urine is dribbled• Encourage exercise,activity

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Wayfinding

Everyone relies on signs and landmarks to find their way through unfamiliar territory.

Consistent cues become crucial for the person with dementia and they

should be thoughtfully incorporated into their daily

environment.

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Wayfinding

Solution: Large pictures can be used as landmarks. If pictures are used in more than one place be sure they are different in color and content so that they

mark a specific location.45

Wayfinding

Solution: Using a theme: On another wing, a bird theme has been used including an aviary, pictures and chair upholstery.

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Wayfinding

Solution:Shallow resident room sign allows space for numerous photos. The residents and/or the resident’s families may place anything that has meaning to the resident. All items must be in good taste and nothing that could be harmful to other residents may be displayed

Wayfinding

Solution: In small lounge spaces at each end of a corridor, furniture arrangements that differ from each other help orient residents as to where they

are.

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Wayfinding

Problem and Solution: It is difficult to determine which floor you are on. When observing the floor from inside the elevator, the decor should be markedly different from one floor to another.

Visual Cues

Beyond adapting for age-related visual changes, visual cues provide help to the person with

dementia by having items in view.

In some stages of dementia, a person does not retain the concept of object permanence. That is, just as a child, he/she does not understand that an

object continues to exist although it is out sight.

Planning and organizing the environment with this in mind can reduce frustrations.

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Visual Cues

Solution: Putting clothing of one type in a drawer and labeling the drawer can be helpful in certain stages of dementia, when the person still retains the

ability to grasp the meaning of words.

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Acuity

Problem: Dishes, placemat and napkin do not contrast in color with the tray.

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Acuity

Solution: Tray of contrasting color with the table, dishes of contrasting color with the tray and the bowl of a contrasting color with the plate - all provide visual

cues.

Memory and Memory Aids

Products and ideas that compensate for short term memory

loss can be helpful.

Pictures and items that were significant in the person’s past or reminders of past events may also

stimulate long term memory.

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Memory Aids

Solution: This clock shows the time, day and date. Analog clocks and not digital should be used for older people with dementia

because it is a style that is more familiar to them.

Memory Aids

Solution: Likewise a non-digital radio will be easier for the person with dementia to understand because it is the type they have used in the past. In the LTC facility, residents, not staff, should decide what

station should be on.

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Memory Aids

Solution: Use a calendar and marked off days to help orient a person to time.

Memory - Personalization

Solution: Personalization of a resident’s room can aid memory.

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General Principles for Home Safety

• Increased lighting• Uncluttered, uncrowded rooms with clear pathways• No loose scatter rugs• No cords in exposed areas (telephone, electrical, etc..)• Grounded plugs• Carpets or rugs that don't impede wheelchairs, walkers or canes• No heavily waxed floors• Easy to read list of emergency numbers near the phone• Escape routes• Smoke and carbon monoxide detectors

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Bathroom Safety• Shower control gauge• No-slip decals or mats in the tub and shower• Installation of grab bars to eliminate reliance on less secure

places to grab• Non-skid rugs or mats to prevent slipping on a wet floor• Bathtub / shower bench, hand held shower• Raised toilet seat• Easy to use faucets • Electrical appliances away from water• Plastic cups rather than glass tumbler• Night light

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Safety

This Anti-Scalding Device installs easily by screwing it onto the faucet. It automatically turns off the water if the temperature gets too hot. Can be installed at bathroom sink, tub or shower and kitchen sink. Information about this product is available at: www.alzstore.com

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Grooming Aides

• Soap on a rope• Suction nail brush• Long-handled sponge / curved bath sponge• Wash mitts• Electric razor (may need holder)• Lever type faucet handles• Built-up handles / bicycle handle / wrist cuff for

toothbrush, hairbrush or comb handles• Extension handles

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Visual Cues

Solution: To help a person with dementia be as independent as possible, items that are used

together should be placed together 63

Bedroom Safety

• Stable furniture at bed height next to bed for support

• Light switches in convenient places and easy to use near bed

• Pathways clear from bed to bathroom• Phone placement convenient and within

reach for emergency• Night Lights in the hall

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Bedroom Equipment

• Urinal for night use• Disposable incontinence garments• Chair with armrests and firm seat• Bed no lower than knee height• Communication device in easy reach

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Walking Safely

• Canes and walkers can be used to compensate for minor balance problems– Rolling walkers may be unsafe on rugs or other uneven

surfaces– Canes and walkers should be of the correct height and

kind to suit your individual needs (There are many different kinds)

• To best suit individual needs, a physical therapist should be consulted to determine the appropriate ambulatory device or wheelchair.

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Negotiating Stairs

• Use handrail as long as it is well secured• If insecure with step-over-step technique, use

one step at a time• If some one assisting , they should

– Stay by the side– Stagger their feet so that their lead foot is one step

down from the residents• If there is difficulty managing steps, specific

instructions should be given by a therapist

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Miscellaneous Tips

• Avoid low couches and chairs – use straight backchairs with arm rests and firm seats

• Use Fone Holder and large push buttons• Pens, pencils, and writing devices are available to

stabilize grip• Weighted pens reduce tremors• Door knob turner fits over the door handle and

converts round knob into a lever

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Falls and Fall Risk

• Fall risks associated with– Age related factors– Conditions/disease processes– Environmental hazards– Acute illnesses– Altered biomechanics– Poor judgment– Perceptual deficits

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Conditions Representing Risk Factors for Falls:

• Previous falls• Fear of falling• Cardiac arrhythmias• Transient ischemic attacks (TIAs)• Stroke• Parkinson’s Disease• Delirium

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Conditions Representing Risk Factors for Falls:

• Dementing illnesses• Depression• Musculoskeletal conditions such as myopathy

and deformities• Problems with mobility/gait• History of fractures• Orthostatic hypotension• Incontinence of bowel or bladder

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Conditions Representing Risk Factors for Falls (Con’t)

• Visual and auditory impairments• Dizziness• Dehydration• Acute and subacute medical illnesses• Use of restraints• Hypoglycemia• Polypharmacy (multiple medications)

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Environmental Factors Associated with Falling

• Dim lighting• Poor or weak seating• Glare• Use of full-length side rails• Uneven flooring• Bed height • Loose carpet or throw rugs

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Environmental Factors Associated with Falling (Con’t)

• Inadequate assistive devices• Wet or slippery floors• Inappropriate footwear• Lack of safety railing in room or hallway• Malfunctioning emergency call systems• Lack of grab bars in bathroom• Poorly fitting or incorrect eye wear• Poorly positioned storage areas

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… RESULTS ...Extrinsic Factors are environmental conditions that may

pose a risk or danger of causing an elderly to fall (Clemson, Roland & Cumming, 1992)

Stairs Obstacles/clutterCerbs/steps

Poor lighting

Slippery floor

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… RESULTS ...

~ Habitual Use of Environment ~ Pre-occupation with existing conditions

...engaging in a routine activity under conditions that appeared to create excessive demands on

one’s capabilities

…excessive attention to a temporary condition, which led individual to ignore or overlook

other potential hazards.

Situational Risk Factors (continued): Patterns of Falls...

E.g. Picking up objects from floor...

E.g. Unaware that the floor is wet, he rushes to close the windows...

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… RESULTS ...

~ Excessive Environmental Demands

~ Failure to Avoid Hazardous Conditions

…inability to detect & avoid hazardous conditions not

normally present

…environmental demands exceeding an individual’s

capabilities to respond to these demands.

Situational Risk Factors (continued): Patterns of falls...

E.g. Going over a high kerb with a walking frame ...

E.g. Presence of dirty shoes near toilet entrance...

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Fear of Falling

• A disability that can be treated– Make them aware of their beliefs and attitudes

about falling– Help them understand actions they can take to

reduce risk– Exercise regularly– Communicate assertively– Find alternatives to potentially risky behaviors

– They need to learn to come up with solutions on their own

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Fear of Falling

• Is common among older adults– Think falls are an inevitable part of aging– Often result is limiting activities– May diminish quality of life– Increases risk of falling

• Need to encourage older adults to:– Discuss their fears– Be realistically concerned about falling– Develop a wide range of fall prevention skills

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Fear of Falling: Fall Prevention Tips for the Older Adult

• Take charge – identify risk factors• Create strategies that fit individual lifestyle and

goals• Must be satisfied with the plan to reduce risk – or

will not follow through• Prioritize actions needed to reduce risk• Exercise – be actively involved• Be assertive making requests (i.e.; For a seat on a

crowded bus)• Have a contingency plan – know what to do if a fall

happens 80

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Fear of Falling: Fall Prevention Tips for the Older Adult

• Acknowledge your concern about falling• Be aware of how your concerns impact physical or

emotional health• Explore negative attitudes about aging and fall

prevention• Practice – prove to yourself that you have the skills

to avoid falls / injury• Be a problem solver – set goals and create action

plans• Re-evaluate your fall risk factors, goals and plans as

need change. 81

Management of Falls:

• Balance between freedom of movement and desire to try to eliminate falling and prevent injuries– Balance safety concerns with freedom and self-

determination– Educate patient and family about risks, possible

consequences and alternatives to restraints -DOCUMENT

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Management of Falls:

•– Permit certain informed risks– Monitor actions of cognitively impaired residents– Create a safe environment

• Develop and use clear policies and procedures on options for interventions

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Managing the Causes of Falls:

• Management of medical conditions– E.G. Recent pneumonia – antibiotics – diarrhea –

dehydration – increased confusion/ general instability

• Medication review• Revision of medication times• Restorative or rehab program for deconditioning

• Enhance strength, balance, gait & transferring• Sit to stand slowly for orthostatic hypotension

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Management of risk factors for serious consequences of falls:

• Create a safe physical environment –especially for wanderers– Wandering paths– Sufficient space for safe wheelchair transfers– Furniture that is safe and arranged so resident can

use to get about– Chairs at intervals for resting spots– Reduce clutter– Adequate lighting

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Management of risk factors for serious consequences of falls:

• Getting out of bed – problems– Lower bed, half rails, bed minders, mat on floor– Bed wheels locked – Night lights, bedside tables, etc.– Middle of the night raisers – offer snacks,

activities, toileting– Commode

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Programs, Policies and Procedures to Attempt Falls Reduction (Con’t)

• Patient education programs about safety, sitting and standing

• Recognizing when independent ambulation is not safe or feasible

• Programs for wanderers• Nutrition and hydration programs• Restraint reduction• Use of bed/chair alarms

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Balance Program

• Improve range of motion• Strengthening component• Gait training on different floor surfaces

– hard/soft-even/uneven• Individual may need to relearn “his balance

point” to maintain his body over the center of gravity

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Balance Program

• Need to relearn to integrate multiple sensory cues in a safe environment

• Educate person about situations that put them at higher risk

• Remove extrinsic risk factors – poor lighting– clutter

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… CONCLUSION ...Falls occurred as a result of the

dynamic interaction between intrinsic, extrinsic & situational factors.

Falls were a major contributor to increased limitation, and an eventual

loss of independence.Falls intervention should involve client education to help individuals recognize & modify habits… as well as to increase

sensitivity to one’s environment (Connell and Wolf, 1997)

Occupational therapists can play a significant role in the management of falls, thus allowing our elderly to ‘age-

in-place’.

This study was conducted by the authors as part of their final year Occupational Therapy Project at Nanyang Polytechnic, Singapore 90

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Coralie “Corky” Glantz OT/L, BCG, FAOTANancy Richman OTR/L, FAOTA

Glantz/Richman Rehabilitation Associates847-945-1917 [email protected] -

[email protected] - [email protected]

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Safety v.s. Independence: The Role for Therapy · • Elastic shoe laces • Front-closing bra •...

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