Home Safety for the Older Person; the Bathroom

Today I want to share more ideas on home safety for the older person.  These are some things that I look at when assessing their safety in the bathroom.  (This is not intended as an all-inclusive list, and it may vary depending on client-specific issues).

• Can they easily and safely access the restroom?  So many of the older homes have very narrow entry ways.  I recently performed an assessment for an elderly man who used a walker.  The entry to his bathroom was 22″ wide!  No way he could get in safely with his walker.
• Is there adequate space to turn in around?  Seems simple, but not really for the person using a walker or other device.
• If the clients bathes rather than showers, are they safe to get into and out of the tub?  Can they clear the step over into the tub (sometimes 14″ high)?  Often times, weakness of the legs and balance deficits will render this simple task impossible.  Sometimes a simple shower chair and a hand held shower hose will meet the need for bathing, without having to sit completely down in the tub.
• If there is a walk in shower, one still needs to assess the client’s ability to step into the shower and clear the threshold into the shower.
• Does the floor have a non-skid surface, or if there is a throw rug, does it have a non-skid back?  (Personal opinion: I recommend removal of throw rugs if there is even a hint of fall risk…)
• Can the person easily access the toilet, and can they easily and safely get up from the toilet?  An inexpensive toilet seat extender with arm rests can make a world of difference.
• Is the light switch easily accessible?  This is especially important for the older person who uses  walker, as they need to be able to turn the light on without removing both hands from the walker.  Also, there needs to be adequate night light in the bathroom.
• As with other areas of the home, the issue of clutter removal must be addressed in the bathroom.

In my opinion, any home safety assessment should include a gait and balance assessment of the client.  Severe balance problems that have not been addressed will probably lead to falls, even if the home is otherwise “safe”.  A word to all life care planners or others who hire a PT to do a home safety evaluation- ask them if they are going to include a balance and gait assessment as well.

Celebrate!

One of my older clients in my physical therapy practice recently told me “As a young man, I never thought I would have so many ailments as I got older.”  He shared with me how, as a young man, every day was worth living.  Every day was a new adventure for him. He lamented now over his inability to do simple things, like walk from his bed to the toilet, or sit up without feeling dizzy.

I have heard this or similar stories many times over the past 20 plus years.  But for some reason, this man and his genuine yearning for something good had an impact on me.  Maybe it was because he was so eloquent at contrasting his life as a young man and an older man, and he did it in only a few sentences.  Whatever the reason, this man taught me a lesson- I have chosen to pursue a profession that involves some level of compassion on a daily basis.  I must use that compassion to celebrate the simple things, not only in my life, but in the lives of those that I serve each day in my work.

May God bless you all, and remember- celebrate the little things!

Orthotics and Prosthetics in the Life Care Plan

Previously on The Life Care Planner, I have discussed various components of the life care plan, including wheelchairs, attendant care, and projected evaluations.  Today, I will review orthotics and prosthetics for those suffering from various injuries.

According to the Amputee Coalition of America, vascular disease accounts for 82% of amputations.  Of those, 97% are lower extremity amputations.  The risk of vascular-associated amputation is greatest among males, and those who are African-American.

For the client who has had an amputation, the life care plan will include projected replacement schedule and maintenance needs for an appropriate prosthesis.  The life care planner will likely need to consult with a prosthetist to obtain information on replacement schedule and associated cost of the prosthesis.  The prosthesis is typically an expensive purchase.  For this reason, it is important to obtain more than one cost estimate for the prosthesis (if possible), and to obtain the cost estimates from providers in the client’s geographical area.

Assessing the client with amputation is an important part of the life care plan.  Simply including cost of future prosthetic needs may not ensure a good medical outcome for the client.  The life care planner will usually need to evaluate the client’s ability to perform such tasks as skin inspection of the residual limb, self dressing and other self care skills, and applying/removing the prosthesis itself.  Deficits in these areas will need to be addressed within the life care plan.  Of coarse, the life care planner may not have access to the client and may not be able to perform such an assessment.  This may be the case when the life care planner is working for the defense by reviewing a life care plan developed by plaintiff’s expert.

Orthotic devices (sometimes referred to as “orthotics”) will sometimes be an integral part of the life care plan for the client.  Examples of orthotics include ankle-foot orthosis (AFO), various splints to aide hand function, and extra depth shoes.  Consider the client who has sustained a severe orthopedic injury involving the leg.  He may be left with nerve injury that leads to foot drop.  An AFO may be prescribed to provide proper positioning of the foot and to prevent tripping during walking.  This client may then need extra depth shoes to accommodate the AFO.  As with a prosthetic device, the life care planner will need to provide for a replacement schedule and associated cost for the orthotic device.

As a physical therapist, I often evaluate patients with amputations and those who need various braces and other orthotics.  I can bring this ability to the life care plans that I develop for the client that may have a need for these devices.  Please contact me if you have more questions.

Home Safety for the Older Person, Part II

Here are more considerations when assessing the safety of a home environment for an elderly loved one.

• Do carpets in rooms lie flat, or are they wrinkled?  Wrinkled, torn carpets will cause trips and falls.
• If there are throw rugs in the home, do they slide or roll up when you push them with your foot?  As mentioned in a previous post, throw rugs are a potential trip hazard in the home of the older person, especially if they are already at risk for falls.  My personal opinion is that throw rugs should be removed from the home if the older person is at high risk for falls.
• In the kitchen, are the stove controls easy to access and easy to see?  Preferably, the controls should be on the front part of the stove, or to one side.  Are regularly used items easily accessible, or do you have to climb to reach items in high shelves?
• Are there portable heaters in the house?  If so,  the area surrounding the heater should be free of clutter.  Curtains should be at least 12 inches away from the heater.

I will focus on safety in the bathroom in a future post.

Shoulder Pain and Spinal Cord Injury

A life care planner is often called upon to write a plan for someone who has sustained a spinal cord injury (SCI).  In these cases, the life care planner may need to consider the effects of aging on the SCI disability.  One of the common problems that occurs in the individual with SCI is shoulder pain.

In 1999, KA Curtis et al published a study on shoulder pain in wheelchair users with paraplegia and tetraplegia.  The authors reviewed the prevalence and intensity of shoulder pain during daily functional activities in this population.  In this study of 195 individuals, they found that 59% of those with tetraplegia and 42% of those with paraplegia reported current shoulder pain at the time of the study.  They recommended that efforts to monitor and prevent shoulder pain should continue after rehabilitation is complete.

Think about it for a moment; can you imagine yourself as a person with a spinal cord injury, totally dependent on the use of your arms for transferring from one place to another?  Now picture yourself having to have shoulder surgery to repair a torn rotator cuff.  You no longer are able to use that arm for transfers, probably for a long time.  At this point, you become dependent on others for this basic mobility skill.

When preparing a life care plan for an individual with SCI, I will address this possibility as a potential complication as the person ages.  (Of course, this depends on the individual for whom the life care plan is being prepared.  Life care plans are written based on client-specific needs, rather than disease-specific needs.)  I do this if for no other reason than to educate the client and their loved ones on protecting their shoulders.  This is a common practice of mine in my physical therapy clinic.  I educate the active SCI patient on the importance of protecting their shoulders.  I also talk to them about what the future may hold as they age with SCI.  For some clients, there may come a time some years down the road when they will need to consider use of power mobility.

Please contact me if you have further questions about this topic or life care planning in general.

Source: KA Curtis, GA Drysdale, et al. Shoulder pain in wheelchair users with tetraplegia and paraplegia. Arch Phys Med Rehabil 1999; 80: 453-457.

Home Safety for the Older Person

I routinely treat elderly patients in my work as a physical therapist.  I will often counsel the patient and their loved ones about being safe at home, especially if I feel they are at risk for falls or injury at home.  Likewise, home safety considerations should be included in the life care planning process for the elderly client.  Some items that one should be aware of in the home of the older person:

• “Busy” floor patterns can create or worsen depth perception problems for the older person.
• Lighting throughout the home is important, even during daytime hours. Areas of perpetual shadow should be addressed with even lighting. Of coarse, the interior of the home should have adequate night light that provides well lit paths to commonly accessed areas of the home (i.e., restroom, bedroom). Make sure that a flashlight is handy at night.
• The aged individual may have skin changes that put them at risk for injury. For example, one may need to consider reducing the temperature of the hot water heater to avoid burns to the older person with frail skin.
• Slips, trips, and falls- Ensure that electrical cords are removed from the high traffic areas of the home.  Keep the home free from clutter.  Consider removing throw rugs, especially if your older loved one uses a walker.

I will periodically post more helpful information about home safety for Mom and Dad as they navigate the golden years!

A Physical Therapist as Life Care Planner

If you have done any investigation into the field of life care planning, you are probably aware that the many life care planners are nurses.  There are others from different medical professions that transition into life care planning, including rehab counselors, physicians, psychiatrists, etc.  However, there are few physical therapists that are also life care planners.  I am a physical therapist (PT) and life care planner, and today I will explain how the life care plans that I develop are enhanced by my background as a PT.

Point One- Training. Physical therapy programs are intense, and entry into these programs is competitive.  The didactic component of professional training in physical therapy includes assessment and treatment techniques for patients with a wide variety of disabilities or impairments.  For example, some of the areas of focus in my PT training included:

• neurology- spinal cord injury, acquired brain injury, peripheral nerve injury, neuropathies, etc.
• orthopedics- spinal fractures, multiple orthopedic trauma, joint replacements, ligament reconstructions, etc.
• the generally debilitated elderly person

Point Two- Experience. I have more than 22 years of experience in the field of physical therapy.  The first seven years of my career were spent as a PT assistant.  As a Physical Therapist since 1994, I have developed a rich background in assessment and treatment of the adult patient.  I am well versed in performing functional assessments to determine deficits in a person’s self care ability, and in determining the need for further PT intervention.

My ability to thoroughly assess functional deficits are a key component in my life care plans.  Many times, this information must be gathered from medical records, or through separate consultation with a physical therapist.  With a good understanding of a person’s functional deficits, I can interact confidently with all of the client’s treating medical team to determine what their future needs are.  I have developed confidence in interacting with the medicial team over the years.

In summary, I am able to develop a life care plan that is thorough and meaningful in determining a client’s future needs.  My ability to determine functional deficits, and the possible effects of aging with a disability put me in an ideal position to be a go-to person for life care plan consulting.  In invite you to visit my website www.nsteplifecare.com for more information.

Who Can Benefit from a Life Care Plan?

Today I want to revive and update one of my posts from 2008 entitled Who Can Benefit From a Life Care Plan? Life care planning is a niche area of practice to be sure, and this post is a good introduction to my chosen area of practice.

A life care plan can be beneficial for anyone who has sustained a catastrophic injury, or suffers from a serious illness.  A good life care planner realizes that the life care plan is developed based on the specific needs of the client, and is not developed specific to the injury.  In other words, a life care plan developed for one client with a complete T12 spinal cord injury will differ from a plan developed from another client with the same diagnosis.  The lives of individuals are too dynamic to identify generic needs based only on their medical diagnosis!  Today, I will identify some of the medical diagnoses that particularly stand to benefit from a life care plan.

Spinal Cord Injury (SCI)
SCI is potentially one of the most devastating of injuries. Many of the care needs for someone who has sustained an SCI are linked to the level of injury. For example, someone who suffers from a high cervical SCI will require a higher level of care than someone with a lumbar level SCI.  The life care plan will include information on a wide range of client-specific needs, including medications, wheelchairs, adaptive equipment, etc.  I also investigate how the needs of the SCI client will change as they age with their disability, and this information is included in the life care plan.

Traumatic Brain Injury (TBI)
The client who has suffered a TBI can have a multitude of needs, ranging from neuropsychiatric to physical rehabilitation.  Also, the loved ones of the injured person (wife, children) may need to be considered in the life care plan. For example, if the husband of a severely injured client with TBI has been the primary care giver in the home, he may need consideration for psychological counseling to help him deal with his loss. If he is to continue as the care provider, periodic respite care may be presented in the life care plan.

Other common diagnoses that life care planners see include cerebral palsy, anoxic brain injuries, amputations, severe orthopedic injuries, and severe burns to name a few.  My 20 plus years as a physical therapist allows me to critically assess the functional needs of any client for whom I develop a life care plan.  Whether you are in need of a full life care plan, or a more limited cost analysis for some aspect of care for your client, I can probably help you.  Please contact me by clicking here.

Projected Evaluations and Therapeutic Modalities in the Life Care Plan

The person who has suffered from a catastrophic injury may have a need for periodic evaluation and treatment from non-physician providers throughout their lifetime. The life care plans that I develop will include detailed recommendations for future evaluations and ongoing treatment. (Future care recommendations provided by physicians will be included in an upcoming post- Routine Future Medical Care.)

In the context of the life care plan methodology, future evaluations and ongoing treatment are considered and documented separately. One will typically see these two areas referenced as “projected evaluations” and “projected therapeutic modalities“.

Projected Evaluations
In some instances, the client will have a need for routine evaluations from various non-physician providers. As an example, consider a 34 year-old female who has suffered a spinal cord injury as the result of a motor vehicle accident. Medical record review, client assessment, and interview with current care providers confirm that she needs annual assessments by a physical therapist as well as a one-time disabled driver evaluation. The entries in the life care plan may look like this:
Item: Physical Therapy Evaluation
Year beginning: 2010 (age 35)
Year ending: 2055 (age 80)
Frequency: 1 PT evaluation every year
Purpose: Evaluate current functional status, make treatment recommendations, adjust home therapy program.
Cost: $150 per unit.

Item: Disabled Driver Evaluation
Year beginning: 2010 (age 35)
Year ending: 2010 (age 35)
Frequency: 1 time only
Purpose: Evaluate driving ability, driving safety, and recommend adaptive driving modifications.

Therapeutic Modalities
Under this topic of the life care plan one will find recommendations for ongoing care based on the client’s needs in light of their injury or disease process. Inclusion of therapeutic modalities is usually based on recommendations from the individual assessment(s) that are covered under the Projected Evaluations heading. As an example, the client receives a physical therapy evaluation each year, as noted under projected evaluations. The ongoing treatment that may result from that evaluation is allowed for and covered under the therapeutic modalities heading.

Communication with current and past client care providers is very important here. This type of consultation allows me to form a picture of the client’s treatment needs, and provides documentation and support of the treatment recommendation as presented in the life care plan.

The entries in the life care plan under therapeutic modalities may look like this:

Item: Physical Therapy Evaluation
Year beginning: 2010 (age 35)
Year ending: 2055 (age 80)
Frequency: 10-12 treatments per year
Purpose: Treat preventable functional deficits, contracture prevention, patient education.
Cost: $100 per treatment.

At NsTEP Life Care, I develop life care plans that are client-specific, rather than diagnosis-specific. This allows for a more accurate reflection of the client’s true needs based on their deficits in care.

Attendant Care in the Life Care Plan

Those who suffer a catastrophic injury may require attendant care at some point in their life. Attendant care can range from a few hours per week of domestic assistance to around-the-clock skilled care. This can be the single most costly recommendation found in the life care plan. For this reason, attendant care is often the focal point of scrutiny within the life care plan.

As with all areas of the life care plan, consultation with the client’s health care providers is an important starting point for determining attendant care needs. This is augmented by my individual assessment of the client. Some considerations that I keep in mind when focusing on attendant care include:

1. Can the client meet their own self-care needs? (Bathing, dressing, catheter care, toileting, medication management, etc.) If not, who has been helping them?
2. If a spouse or other loved one has been providing care, how many hours per day? Does this person have other care responsibilities (ie children or other dependents)? How long have they been providing this care?
3. Based on an assessment of the client, what exactly are the needs that are not being met?
4. What are the recommendations of the client’s medical providers (doctors, therapists, etc) regarding their attendant care needs?
5. Does the client’s diagnosis itself speak to the possible need for attendant care? (For example, a cervical spinal cord injury tetraplegic with history of frequent hospitalizations and pressure ulcers…)
6. What level of care is appropriate? Does the client simply need domestic help for cooking, light cleaning, etc? Does he or she need skilled care, such as a certified nurse aide, LVN, RN? Do they need a combination of both?

Ultimately, it is usually to the greater benefit for the client to be cared for in the least restrictive environment. However, the needs of the client may sometimes may make it unreasonable to provide quality care strictly in the home environment. It is at this point that care in a nursing home or community living center may need consideration.

When I complete a life care plan, and the needs of the client are extensive regarding attendant care, I may present more than one option for providing the care. One option may be a detailed break down of their needs to stay in their home with attendant care. The other option may include living in a nursing home or community group home. Additionally, I will seek cost information for the care needed from multiple sources within the client’s geographical area. It is always preferable to seek real cost in the client’s geographical area, rather than relying on national or regional cost information.

Much of attendant care needs may revolve around meeting the client’s functional requirements. This may include transferring out of bed, to/from a toilet, assisting with pressure relief in a wheelchair throughout the day, dressing and grooming, etc. As a physical therapist, I am uniquely qualified to look at these functional areas of patient need, and make recommendations in the life care plan that will enhance the client’s independence, autonomy, and overall well-being.

For more information on my company, NsTEP Life Care, please visit my website at www.nsteplifecare.com.