Toni Talks about PT Today : Geriatrics

Physical Impairment Doesn’t Equal Impaired Cognition

Toni Patt — Wed, 16 Sep 2009 15:48:00 GMT

Last Saturday, one of my patients complained to me about the nurses. He was frustrated that he was being spoken to like a child. His words to me were "I'm not stupid." The man isn't stupid, but on initial presentation he could give that appearance. He...(read more)

Some Thoughts on Aging and PT

Toni Patt — Wed, 17 Jun 2009 21:07:00 GMT

I started a new class this week about geriatrics and the process of aging. The opening chapter addresses the definition of aging and theories of why it occurs. It wasn't very exciting. I've read most of it before. The section on increasing life expectancy,...(read more)

Patients are Getting Sicker

Toni Patt — Wed, 08 Apr 2009 12:53:00 GMT

I've noticed something over the last several months. The patients I've been treating are sicker and more involved than they were even two years ago. I'm not sure when this started or why. But it's been happening and gradually getting worse. The patients...(read more)

Caregiver Stress

Toni Patt — Tue, 10 Mar 2009 19:42:00 GMT

Now that I've finished up this round of classes, I have time to catch up on everything else. I finally got to look at the most recent "Geri-Notes." It's the journal of the Geriatric Section of the APTA. In it was an article by William Staples, PT, DPT, GCS, looking at the stresses of care giving. I've often found myself wondering how some elderly people were able to manage to care for their loved ones at home. These caregivers weren't that healthy themselves, yet they had taken on the care of someone else. Those care recipients were also elderly with multiple medical problems and impaired mobility.

Staples cited research that identified the four most frequent stresses these individuals encounter. They are disorganization of household tasks, sleep disturbances, lack of social interaction and inability to get away at the holidays. I think lack of respite care and limited resources could easily be added to that list. I now understand why some caregivers view a hospital stay as an excuse to stay home. They need a break. A hospital is one place they know their loved one will receive adequate care. It might also be why I've seen some caregivers drag out the discharge process.

According to Staples, putting someone in a nursing home isn't always the answer. That is associated with its own unique stresses. I've often wondered why some people refuse to put someone in a nursing home when it's obvious the level of care needed is too much for one person. It seems like it would easier to let the nursing home take over the responsibility. Staples points out that admitting someone to a nursing home may create a feeling of failure because the caregiver could no longer keep the person at home. This also explains why some family members are never happy with nursing home care. They're judging the care against what they provided at home. In that comparison the nursing home will always come up short. I've also met caregivers who consider it a source of pride to describe all the things they've given up to care for a loved one.

I've read many articles documenting the problems experienced by caregivers. These include depression, isolation, failure to care for themselves and premature mortality. It's also been established that the majority of these caregivers are women. Women aren't known for taking the best care of themselves. My women friends, with myself included, aren't the best at taking care of ourselves. Sure we're busy but we could make the time if we had to. Compare us to an older women taking care of her husband. Making the time isn't her problem. To go to the doctor she either takes her husband with her if she can or must find someone to watch him while she is gone. I wonder if there is a relationship between the stress of care giving and the increasingly complex illness we're seeing in older women.

As PTs there's not a lot we can do. Increasing the functional status and mobility of the patient will relieve some of the burden for awhile. We can educate the caregivers on time saving techniques. We can provide information about available resources. I think the biggest thing we can do is listen. PTs are among the few outsiders who have some idea of what they're going through. We can also answer questions and offer support. These caregivers probably don't have many outlets for their feelings. Giving them a chance to let it out may be the best thing we can do.

Staples, W. (2009) How stress affects caregivers of people with chronic illness and dementia. Geri-Notes. 16, 9-11.

Home Programs

Toni Patt — Thu, 05 Mar 2009 17:17:00 GMT

Home exercise programs are a part of physical therapy. We give them out regularly in just about every setting. A lot of thought and effort goes into developing the best program for each patient. Now that frequency and duration of therapy is decreasing, HEPs are taking on added significance. The more exercises I can get a patient to do at home, the more I can accomplish in the few visits I have with the patient. Therapists approach HEPs as a method to increase the effectiveness of treatment. There is a direct relationship between exercise and increased strength, balance, etc. That's how I've always thought about HEPs. I never thought about it from the patient perspective until recently.

Patients don't always see the HEP program as an extension of therapy. Non-compliance is a universal problem. Over the years I've tried many things to improve compliance. I've given fewer exercises. I've explained repeatedly the importance of the program and what it is supposed to accomplish. I've had patients practice over and over again before sending them home with the written program. I frequently wondered if the patient would perform the program. I never wondered if the patient could follow the program. After all, we had just practiced it in therapy. I think all therapists assume if we give a written program the patient will be able to follow it. What if the patient can't?

One reason is a language barrier. In Texas we have a large population of Spanish speakers. Texas isn't the only state like this. Many of these individuals find their way to therapy. Back in the day, before computer generated programs, I had to rely on stick drawings and a Spanish-speaking co-worker to translate. Now I have computer programs that translate the program I just developed in English into Spanish. I'm sure this has improved compliance. While many Spanish speakers don't read English, they do read Spanish.

A less obvious, but more far reaching problem is the inability to read the program. Many of our patients can't read any language. They aren't able to follow the HEP because they can't read the directions. This occurred to me as I researched illiteracy and physical therapy for a recent assignment. I've always taken for granted that my patients were able to read whatever I gave them. And, considering the settings I've worked in, that is probably true. It would never occur to me that the reason for non-compliance is inability to read the program itself.

The problem isn't limited to language and illiteracy. Inability to read can also arise from visual problems. I can't read something if I can't see it clearly. Many elderly have vision problems. It never occurred to me that an elderly patient wouldn't be able to see the directions. I work with the elderly all the time. I automatically raise my voice and speak slowly. I'm careful to avoid white on white when working on mobility. Until a few days ago it never occurred to me to use larger print when issuing a HEP. I've started wearing cheaters to see smaller print. If I didn't have them I would probably have some trouble reading written directions in normal-sized type. I can easily see how doing the exercises isn't worth the effort of trying to read the instructions.

From now on I'm going to ask my older adult patients if they can read the HEP before I issue it. With all of today's modern technology there must be a way to increase font size if necessary. It's been awhile since I've used one of the computerized exercise programs. Next time I do I'm definitely experimenting with changing font size. I'm also going to print it as dark as possible to increase the contrast on the white background. Darker printing is easier to read. It's been a long time since I've used a copier that couldn't enlarge. That's always a last resort.

I'm amazed how I took this for granted. I've started to wonder what else I might be missing.

Please Take Your Medicine

Toni Patt — Thu, 05 Feb 2009 18:50:00 GMT

Yesterday at the barn, an interesting topic came up while we were waiting for a lesson. LH mentioned that her mother had a stroke because she hadn't been taking her blood pressure medication. Her mother recovered, but isn't as sharp as she once was. LH and the others couldn't understand how someone could have high blood pressure and not take their medicine. I didn't answer that, but there are several reasons. High cost and forgetfulness come to mind. In the case of LH's mother, the reason was simple. She didn't think anything would happen to her if she didn't take the medication. I've lost count of the number of times a patient has told me that.

Medicines are prescribed for a reason. In the case of high blood pressure, it is to prevent hypertensive emergencies that can result in strokes. It's kind of scary to think of all the people walking around who aren't taking prescribed medications. On one hand it means PTs will always have patients. On the other hand it means all those people are taking an unnecessary health risk. Many won't be as lucky as LH's mother. She returned to her prior functional status and is living at home. LH said she admits to not being as smart as she once was. It's sad to know that could have been prevented.

Ironically, the other women in the conversation all went on to remark that they hadn't been to the doctor in awhile. One admitted she needed to go. These women are close to my age. They're nearing menopause when hormonal changes increase the risk of heart attack, osteoporosis and breast cancer. Yet none of them saw any need to actually go to the doctor. I'll admit I'm bad about going, but I do. I wonder how many PTs can say the same thing. I think my group of friends is representative of people everywhere. It's scary to think what might happen to the demand for PT services if this trend continues as the baby boomers age.

This has made me wonder about something else. Who is keeping an eye the health of our parents? If LH had known her mother would have a stroke, I think she would have been more involved in the medicine issue. I can see how someone wouldn't think about it with a healthy parent, but what about individuals whose parents are ill? I do a lot of education with families about home programs and safety. Now that I've been thinking about this, it might be a good idea to mention compliance with medicines. All I have to say is something like, "Remember to take your meds regularly to help prevent falls." I often joke with patients I want to see them again as visitors not patient. By saying that I'm within my scope of practice and encouraging a positive behavior. I might even be lowering my future caseload by one. That would be a good thing.

Functional Matters

Toni Patt — Wed, 14 Jan 2009 19:45:00 GMT

We have a new lunch table topic at work. Another therapist and I had seen the same patient a week apart. She performed the initial evaluation. I performed a re-evaluation a few days later. Our objective values were about the same. She put the patient on caseload. I didn't. Her reasoning was that the patient needed to get out of bed and nursing wouldn't do it. My reasoning was lack of functional goals. The patient was an elderly lady who lives at a nursing and is dependent for all mobility and transfers at baseline. The restorative staff lifts her out of bed every morning and returns her in the evening. That stopped when she became hospitalized.

This isn't the first time I've had this discussion. My position is a therapeutic intervention must somehow correspond to a functional goal. A patient with a new onset of a CVA may be a dependent transfer when evaluated but has the potential to progress. Therefore a functional goal can be assessed. A patient who has been dependent at baseline, is dependent at initial evaluation and does not have the same potential. While I agree being out of bed is therapeutic, a total lift transfer is not. The exception is a new low level brain injury who needs to be out of bed for coma stimulation. The few transfers are therapeutic because monitoring and assessing is taking place.

The purpose of therapy is to increase function and independence. For that to happen, the patient must be able to participate in therapy. Particularly in a rehab setting, there must be teachable moments and carryover to create improvement. Providing training to a dependent patient's family is also functional because the family has the potential to learn. Knowledge of body mechanics is vital to prevent caregivers from becoming injured. The transfer is functional because the family is being taught.

A dependent transfer is not a skilled intervention. It does not require the special skills of a patient. Almost anyone can perform such a transfer with a little training. There has to be more emphasis on interventions only a skilled PT can perform. This is one of the arguments in support of the PATIENT. We provide a skilled service because we are the only ones who can do what we do. I can't charge for a non-skilled activity because it isn't something only a PT can do.

I know my co-worker meant well. She was thinking of what was best for the patient. I'm not saying the patient doesn't need to get up. I'm saying it isn't a skilled service and therefore the patient is not appropriate for caseload. We are PTs. We have special skills and training. We need to be careful how we use those skills. Many, many years have been dedicated to separating ourselves from other disciplines and moving away from the idea that all we do is get patients out of bed.

Letting Go is Hard

Toni Patt — Thu, 04 Dec 2008 13:02:00 GMT

I've finally made up my mind. My 3-year-old horse is going to his first show this January. This was a tough decision for me. I want him to be ready. I want him to do well. So I waited until the last minute to make a decision. I know he'll make mistakes. This will be a new experience for him. I can't protect him forever. He was bred to be a show horse. Sooner or later he has to go to his first show and make mistakes. The longer I wait, the longer it will take for him to mature into a well-trained horse.

I do the same thing with some of my patients. I don't want to let them take chances. I want to protect them. In a sense I'm reluctant to let go of the gait belt because there is a chance of falling once I do. I want everyone to be completely safe. Most of the time I don't have a problem letting go. Other times I have a patient who doesn't look completely stable but can walk. Or I have a patient who can walk but doesn't have the best pattern. These are the ones I want to keep working on. They're almost ready. Like the half-empty or half-full glass, I see a fall risk while the patient sees independence. Just like with my horse, I have to stop protecting them.

I'm not going home with any of my patients. I can make safety recommendations. I can request home health. I can do family training. That's all I can do. Once the patient leaves the hospital I can't make him use a RW. I can't stop her from furniture walking. If I couldn't convince someone to something in the hospital, I surely can't make it happen at home. All I can do is get someone as safe as possible and then step back. No one wants to fall. No one is going to deliberately do something that will result in a fall. Patients do things at home that aren't completely safe but I've yet to have one back the next day after falling. This is my problem. If I don't let go, I never give the chance to move forward.

The ones I worry about the most are those elderly who live alone. They are used to taking care of themselves and being independent. Sometimes that clouds their judgment about what is safe. I frequently recommend SNF prior to DC home for these individuals. Usually it's a good idea. Sometimes it's not necessary. I don't think I'm seeing the full individual. I see a person who looks unstable and uses a RW and thus requires as much therapy as possible. The patient may see the hospitalization as inconvenient and therapy unnecessary. As I've been told many times "I get around just fine." As much as I want to worry I have to let those people try.

In the case of my horse, the worst that happens is we don't win anything. I'm not expecting to win. He doesn't care. The stakes are a little higher with a patient, except instead of winning they don't expect to fall. I think that belief goes a long way. Positive thinking is said to promote positive action. Thinking I won't fall may very well prevent falling. When I ride I don't worry about falling off. If I did I could be seriously hurt. If I'm willing to take such a chance why wouldn't a patient be willing to take the safe risk to live independently? I can tell all the fall prevention and safety awareness training I've had trying to block out common sense. I usually catch myself and obviously need to keep working on this. Letting go of a patient may seem risky to me but it's a necessary risk.

My Therapeutic Pet Peeve

Toni Patt — Tue, 25 Nov 2008 18:26:00 GMT

I have a pet peeve. Actually I have several. This is one that pops up while I'm at work. What is my pet peeve? It's patients who think going to therapy means going to the bathroom. I'm not talking about those who I bribe with the bathroom to get them out of bed. Nor am I referring to those who would have gone earlier if someone would have come to assist them. In the first case, I'm using the bathroom for therapy. In the second case, it takes only a few minutes to resolve, then we're off to therapy. I'm talking about those patients, who despite what I say or try to do, insist on going to the bathroom. Instead of doing therapy they use the bathroom.

I had a good example of this last week. I had a spine patient. OT had already worked with him. I needed to do bed mobility, transfers and gait. Since he was up in a chair we did gait first. That was all we did. As soon as he was up, he headed for the bathroom. It took 10 minutes to walk 15 feet. He wouldn't stop. He wouldn't rest. He wouldn't sit down. I couldn't leave him because he would have fallen. By the time he made it there, urinated and walked back, he refused to continue therapy because he was in too much pain. The most annoying piece of this was the urinal hanging off his chair. He'd been using that all day.

There were so many other things I needed to work on. Log rolling is very important for spine patients and we didn't do it. So is transfer training, but we didn't do that either. Ten minutes of the time I spent with him was therapeutic. In most facilities, therapy time is limited, case loads are long, staff is short. Coming back to a patient isn't often an option. Even if I had the time, it's very possible the patient would be gone for a test or procedure. This happens all the time with neurological patients.

So, I get frustrated. I have limited time and lots of therapy to provide. I have to cover the big stuff first. Later, if there is time I can do more involved therapy. Patients aren't in acute care hospitals for therapy. They're there to become medically stable so they can move to the next level of care. My job is to get a patient as functional as possible by the time that happens. This isn't ideal. It's probably one reason many therapists don't like to do acute care. It still has to be done.

I'm not unsympathetic to these patients. I'd want to use the bathroom too. The problem is conflict of priorities. I want to do therapy. They want to use the bathroom. Taking someone to the bathroom isn't necessarily skilled or therapeutic. My job as a PT is to provide skilled and therapeutic interventions. If the need is urgent, BSCs are a good alternative. The transfer doesn't take long and can be used as training for other transfers. That way I still get plenty of time to do other things. Even changing a diaper while less therapeutic, unless rolling is a goal, is quicker and uses little energy. I can't stop patients from ignoring me and heading to the bathroom. Short of forcing them into a chair, which I can't do, I have little choice. I think the psychology of using the bathroom would be a fascinating research topic. There might be a solution in there somewhere. In the meantime I will continue to have this pet peeve.

I Want To Do It My Way

Toni Patt — Tue, 18 Nov 2008 21:17:00 GMT

Anyone who works with elderly patients knows they can be stubborn. They latch on to things from years ago and refuse to change. This becomes obvious when they are receiving PT. I can't count the number of times I've been told "I always do it that way." The "it" can be transfers, ambulation, choice of assistive device or shoes. It doesn't matter to them if their "way" is unsafe or not functional. It doesn't seem to matter if a new deficit is preventing them from doing things as usual. They will still tell me, "That's the way I've been doing it. That's the way I‘m going to do it."

Elderly patients can be resistant to change. It can be a challenge to get some elderly patients to understand the old method is no longer safe, functional or even possible. I've been told I'm wrong. They will try to prove to me I'm wrong by showing me how well their way works. That can be scary to behold. Sometimes I find myself wondering how some have managed not to fall. Another thing I'm told is their way is easier. It doesn't matter how involved their way actually is. It's always easier. I've had patients become resistant because I won't let them transfer or walk their way. It doesn't seem to register that they can't do it their way anymore. Pointing this out doesn't help. There's always a reason. The bed is too high. It's the wrong kind of walker. The chair at home is different.

Transfer training is a good example of this. I've had patients work much harder than necessary to do it their way. I've had patients refuse ADs because they insist one isn't necessary. They tell me not to hold on when they transfer. They tell me I need to lift them because that's what the caregiver at home does. When it's safe I'll let them try. Usually they fail. Sometimes I'm wrong and will be the first to admit it. Even when someone is open to alternatives things can be challenging. Many elderly don't like to be helped. Often they allow me to hold on if I promise not to help. That's safer than some alternatives.

Disbelief that something isn't possible is also a problem. Many times I'm told, "I could do this before I came into the hospital." Of course that's usually pre-joint replacement, pre-stroke or pre-surgical procedure. That kind of stuff will slow someone down. These patients are easy to work with because they recognize there is a problem and therapy is necessary.

Others simply believe therapy isn't necessary. These patients insist they'll be fine if I will just help them up. Sometimes they're right. Usually they're not. Often that's enough to gain cooperation with therapy. The worst of these are those who lack safety awareness. They don't see the point of therapy because they don't see a problem in the first place. They'll tell me they fall. In the next breath they'll tell me they walk just fine. I've had them tell me they won't fall if they use the walker. But they don't like to use the walker so they fall. It can be next to impossible to convince these patients to work with therapy.

My favorite group of elderly are those who insist they'll be fine once they get home. These patients won't get out of bed. They'll just lay there and tell me they're fine. They'll be still be saying this when the ambulance comes to take them to the SNF. A closely-related group are those who will work with therapy. They make good progress. At some point they tell me they'll do what I want but aren't going to do things that way when they get home. These patients know how to do things safely and properly. They simply aren't going to do so after discharge. They really make me want to pull my hair out.

I like my geriatric patients. They can be a challenge, especially the hard-headed ones, but they're a great group to work with. I'll take an 80 year old over a 50 year old any day. When I run into problems I talk to them as an adult and explain why I want to do what I want to do. I also ask questions because sometimes there is an underlying cause for doing things the old way. Then we can work together on the solution. There is still a small group of these patients who aren't going to be easy to work with. They're just ornery. That's a Texas term. It means mule headed.

You Must Like Where You Work

Toni Patt — Thu, 23 Oct 2008 13:29:00 GMT

Last week an OT scolded me. She found out I have McKenzie credentials and couldn't believe I was working in a hospital. She told me I had to be in an OP setting treating spine patients. She even asked me why I was working in a hospital. Shouldn't I be using those skills to treat spine patients? For her information, I work in a hospital because I enjoy it. I don't like working in OP clinics. I worked hard to get those McKenzie credentials. After awhile I realized I preferred working in a hospital. While I may be an anomaly, that's how I feel. I like medically-complex patients. I don't get that reducing derangements all day.

Her statements raise an interesting question. Why should I use my spine skills in a setting I don't enjoy when I can use my neuro skills in a setting I do enjoy? I don't think one patient population gets priority over the other. God knows there aren't enough PTs willing to work in hospitals as it is. Isn't it a good thing that I want to do that? All PTs have skills they don't use. After being in the profession for a while they gravitate toward the setting and patients they prefer. Thus we have pediatric therapists, cardio-pulmonary therapists, wound specialists and the like. I could ask my company to place me in OP clinics. But I wouldn't want to stay very long.

I chose this setting because I like those patients. I didn't decide on hospitals because they pay more. They don't. I have a problem with PTs who take positions based only on how they pay. These are people who are in it for the money. They're pretty easy to pick out, too. Sometimes they fall into a comfortable little routine where they're not overly happy and not overly unhappy. I work with one of those right now. I know therapists who took positions in SNFs for this reason. They don't particularly like the elderly population. They also can't understand how I get their patients to do more with me. I like the elderly and it shows. I'm worried about what's coming in the future as more PTs graduate with higher debt. That creates an incentive for making money.

If someone isn't happy it's pretty obvious to those around them. An unhappy therapist does the minimum and complains. While unintentionally doing the minimum also means patients are being short changed. If I'm not doing my best, my patients aren't getting the best. What the OT failed to realize is that I'm working where I'm happy. So what if I save my manual therapy skills for my horses. The patients I'm working with are improving. Isn't that the most important thing?

Society Needs to Rethink Elder Care

Toni Patt — Tue, 09 Sep 2008 18:36:00 GMT

I've noticed a disturbing trend when developing discharge plans for elderly patients. Families aren't as involved as they once were. When I first practiced therapy discharge plans weren't a problem. Families took patients home to care for them. Sometimes home health was needed. But the bulk of care was provided by the family. Putting someone in a nursing home was almost a social taboo. It happened but the person had to be very, very sick or have no family left. Families were not only available but willing to help.

That isn't the case anymore. Whiles spouses can almost always be found at bedside, children are another story. Many times one spouse will move into the hospital room to care for the other. People who can barely care for themselves are ready and willing to take the other one home. Children, on the other hand, seem to be MIA. Of course I'm not talking about everyone. Some children are very devoted. Others can't seem to be bothered. When I do evaluations, one of the questions I ask concerns family availability to assist with care. I've been told many times the children are too busy with their own lives. That statement makes me wonder.

I can understand wanting to remain independent. Asking a child to help could be seen as a step toward losing independence. Those on the brink of losing independence might consider asking for a help a sign of no longer being independent. I hate to ask for help. I've had to face that there are some things I can't do for myself or by myself. I don't like it but I get help. When this is the case I can understand the reluctance to ask the kids to help.

I'm more concerned about children who don't want to be bothered. These people have numerous reasons why they can't help that usually involve being too busy or having their own problems. One statement seems to sum it up. No one wants to make the lifestyle changes that would be necessary to care for an elderly parent. I've heard litanies of illness, work, distance and obligations. I've been told houses are too small. I've been told work is too demanding. Money, or lack of it, is always a problem. Those that have it don't want to spend it. Those that don't have it want things to be paid for. Social workers talk about families expecting Medicare to pay for everything including sitters and home care givers.

Nursing homes fill a need in the health care continuum. An SNF stay is temporary to allow someone to regain independence. Residential living is available for those with no other option. An SNF is not a dumping ground for the elderly to be dropped off and forgotten. The same applies to emergency rooms around holidays. It makes me wonder about society. Somewhere along the line priorities changed. Some people have no other choice. They have no family, have no resources or require too high a level of care for home to be realistic. In other cases the priority isn't caring for the elderly but making arrangements for care. I don't think this is a change for the better.

Many years ago the elderly were valued members of our society. The care they received reflected this. Our society has changed resulting in a change in values. This is reflected in the way we treat the elderly. Some individuals do everything in their power to care for parents or grandparents which often requires sacrifice on their part. Others don't feel this way. Some are caught in the middle. I don't have a solution. I'm making an observation. I think it's a shame.

Care Giving is a Two Way Street

Toni Patt — Tue, 12 Aug 2008 16:41:00 GMT

My class is finally coming to an end. The last topic addresses women as caregivers and the stress that results. In the United States, at least 75 percent of home caregivers are women. Depending upon the amount of care required, they can spend up to 16 hours per day providing care. In addition to being caregivers, many have families and jobs.

Others are elderly spouses who lack the time to tend to their own medical problems. Research has found that being a home caregiver is an independent variable for early mortality. The focus was for us to become aware of the problem. As therapists, we were asked how we could address this in our clinical settings.

As we discussed the topic something interesting came up. Many of us commented on having met patients who add to the burden of care giving by being difficult or demanding. Everyone had an example of someone who wouldn't help with transfers, wouldn't let anyone but the caregiver help them and constantly needed a pillow moved or the head of the bed adjusted. I've had patients who demanded their caregiver stay with them while they were hospitalized even though nursing and others were available to assist them. Given patients like these, it's easy for me to see why caregivers are exhausted and frustrated.

The odd thing is the same patient who won't help her daughter with transfers will walk 100 feet with me. Or, the man who can't assist with a bed bath will be supervision for a shower with OT. I've lost count of the number of times I've heard "she won't do that at home." I could probably make a fortune if I collected and sold on Ebay the unused equipment well-meaning doctors have ordered that the patient won't use. The equipment is meant to save time and make things easier for the caregiver. That doesn't happen if the patient refuses to let it be used.

Home health is a community resource that is heavily relied on. Again, the intent is to help the patient get stronger so he or she can assist with care. Home health therapy only helps if the patient participates. This is another source of frustration. I've been told many times therapy came to the patient's house but mom or dad didn't like it, so they stopped coming. I've had patients tell me they didn't like the therapy because it was too hard. Hospitalized patients tell me the same thing. I'm not sure where the perception that therapy should be easy came from.

I've seen husbands and wives hostile toward therapy. He pleads with her to do therapy. She refuses because either she can't or she's too tired. I've had daughters and sons plead with parents to work with therapy to get stronger to no avail. Many times these are patients who could easily get up and mobilize but won't. This makes me wonder who will become the new caregiver when the current one is no longer capable of providing care. I also wonder about families and jobs that are lost due to caregiver duties. I have a friend in this situation. She is a caregiver for her mother. She told me her mother gave up her life to take care of her grandmother for many years. Now she expects the same.

I'm sure there are many reasons for this: fear, pain, confusion as well as wanting to be waited on. The average caregiver provides $35,000 annually at home. Baby boomers are starting to age so the cost and demands will increase. Many women put their lives on hold, neglect their own needs and medical conditions to provide care. We therapists are in a unique position to offer help. We can work with the patient to overcome barriers to assisting. We can work with the caregivers to help them ease the burden. Sometimes the best thing I can do is tell the caregiver it's OK to take a few minutes for herself.

What's Wrong With a Walker?

Toni Patt — Wed, 06 Aug 2008 13:31:00 GMT

Why don't people want to use walkers? I've been asking myself this question a lot lately. I've had several patients who need to use a walker for safety but refuse to use one. Not only did they refuse to use one, but they told me they didn't need one and were offended that I mentioned it.

As a therapist, one of my first concerns is safety. When I do a gait assessment, I look at gait pattern, balance and foot placement. Not only do I assess what I will need to address in therapy, but how I can make them safe to walk today. Frequently this means use of an assistive device such as a walker. My intention is for the patient to use the walker now while working in therapy so it won't be needed later. Falls, particularly fractured hips resulting from falls, are among the top causes of disability and mortality in the elderly. A fall can lead to loss of independence and significant lifestyle changes. Naturally I want to prevent this. It seems clear to me. Patients, on the other hand, have trouble with this.

I worked with one woman who was referred to therapy for gait training. She'd fallen prior to admission so the physician was concerned. She insisted on walking unsupported. It was quickly obvious she was unsteady and a fall risk. I mentioned using a walker. She looked at me like I was speaking a foreign language. She told me she didn't use a walker before and wasn't going to use one now. Another patient told me she had a walker at home but didn't use it because she didn't need it. She did. A third told me not to worry. She walked better at home because she could hold on to the furniture. I don't run into this when I mention a cane.

Leaving a walker in the room doesn't help. The walker will be pushed out of the way so the patient can get up without it. When I try to work with these patients they refuse therapy because they don't need it right now. One woman, who was very unsafe, had a walker in her room. She used furniture to walk around her room as she explained to me she didn't need therapy. She then instructed me to take the walker with me because she didn't need it. I think it would be an interesting study to go over fall incident reports to see how many of the patients had walkers in the room they weren't using.

There must be a negative perception surrounding using a walker. No one seems to want to use one. For some reason it is more important to be getting around "by myself" than it is to be safe. Even those who acknowledge needing one tell me it will only be for a few days. I wonder how many walkers are sitting around gathering dust because the owner won't use it. I believe people must think less of themselves if they have to rely on the walker to get around. Maybe it makes them feel old. Some might see it as the final loss of independence. I understand how someone might feel that way. What I don't understand is why patients are resistant to being safe. The best I can do is stress that using a walker today doesn't mean it will be needed forever.

Osteoporosis

Toni Patt — Tue, 24 Jun 2008 14:59:00 GMT

This semester my class is about woman's health from midlife to beyond. We're studying disease processes that typically affect older women. Last week the topic was osteoporosis. I thought that would be pretty basic. It's caused by loss of bone mass. It's treated with weight-bearing exercises. I've never had a patient with that as a sole diagnosis so I thought there wouldn't be much to it. I was wrong.

My eyes were opened. I was surprised at how little I actually knew. At the same time, I found myself making connections between things I knew but never saw as significant. I always associated osteoporosis with compression fractures. It never occurred to me that other bones such as hips and wrists are also involved. I had the misconception that osteoporosis is responsible for broken bones. I learned that falls break bones. You can have osteoporosis for years and never break a bone. Falling will break a bone whether or not the person is osteoporotic. I was right about compression fractures, but wrong that there is no treatment therapy can offer.

I had to stop and think. Fractured hips are one of the most devastating problems an older person can face. Billions are spent annually on treatment alone. Falls are one of the top five causes of death in the elderly. PTs can do something about this. We can teach fall prevention. Reducing the number of falls will reduce the number of fractures. Prevention of one fall keeps one elderly person home longer. Extension and back strengthening exercises have been shown to reduce a thoracic kyphosis. A kyphosis impairs breathing mechanics. Inadequate lung expansion has many nasty side effects.

There are other things we can do. We can include resistance exercises in treatment programs. We can encourage women to become more active. We can promote weight-bearing exercises such as walking. We can educate women on improving their diets and taking calcium. We can encourage those taking antiresorptive agents to be complaint. These drugs work, but take time.

I'm rethinking how I will approach older women patients. I'm going to add some bone strength education and include weight bearing and/or resistive exercises when I can. I'm also looking at myself. Fortunately I'm already doing the right stuff like taking a calcium supplement. I get weight-bearing and resistive exercise when I ride. I'm in the sun a lot so I'm getting plenty of vitamin D.

I'm sharing this with as many PTs as I can. I think others have the same misconceptions I had. I wouldn't have learned differently without this class. I'm sharing in my blog because many of us treat older women. This is something we need to think about when planning treatments and providing education. I have one last thought. While women are predominately the ones who have this, it isn't exclusively a disease of women. Men can benefit from education, too.