Transcript Strategies for Delirium - Divisions of Family Practice

Disability Management
- an overview Dr. Jill Calder
Physical Medicine & Rehabilitation
February 8, 2015
A bit of background: Physiatry
Physical Medicine & Rehabilitation
(PM&R) = USA / Canadian term
Physiatrist = British / old Canadian term
“fizz-i-a-trist” not “si-ci-a-trist”
Born from challenges
of the 20th century:
Wars
WW I
WW II
Korea
Vietnam
TBI, PTSD, Amputees
Field surgeons
MASH
Air evac
Epidemics
Parkinson’s
Polio
Aging
the coma
survivable paralysis
boomers . . .
Current epidemics
Our highways,
guns and violence,
work and leisure pursuits,
ageing.
The Medical Mind:
Symptoms History Physical signs
Urine tests Blood tests Xrays US
CT scans MRI Angiogram
Diagnosis
The Rehabilitation Mind:
Diagnosis
Functional Diagnosis
Joint range
Speech
Cognition
Strength
Swallow
Behaviour
Sensation
Communication
Emotion/Mood
Self care
School
Bowel
Home care
Work
Bladder
Community access Driving
Control
Sexual Function
Finances
What is a Disability, or Challenge?
WHO 1980
WHO1997
Impairment
Impairment
Disability
Handicap
Activity
Limitation
Participation
Restriction
The same impairment leads to different
disabilities / activity limitations . . .
Handicap?
• Handicap used to be a
compliment!
• The better the horse, the more
weight added to even up the race.
Modern English keeps changing:
• Handicap is not a positive word
anymore.
• REPLACED BY -
“CHALLENGED”
“Participation Restriction” has not caught
on but good for reports.
English
Medical
Legal language:
Visible disabilities
Terry Fox – ordinary guy, who
fought cancer. Amputation is a
visible disability.
Rick Hanson – ordinary guy who
suffered a spinal cord injury.
Paraplegia is a visible disability.
Christopher Reeves –
Superman, super actor, suffered a
high spinal cord injury.
Quadriplegia is a very visible
disability.
Their disabilities were not THEM,
not really WHO they were. Their
disabilities were their challenges
by as they lead their lives.
Invisible disabilities:
Complex Brain Functions
Tom Cruise – learning disabled?
Paul McCartney –
music impaired?
Wide range of patients, and systems
Gradations of Disability / Return
to Work concepts
1. Return to previous work without limitations
2. Return to previous work with modifications
3. Graduated return to work
– Modified by duration, intensity
– Example:
• 3 half days alternate
• 5 half days
• 3 full two half . . . etc.
4. New job, same employer
5. New job, new employer
Gradations of Disability
1. “temporarily partially disabled”
2. “temporarily totally disabled”
3. “permanently partially disabled”
4. “permanently totally disabled”
– “from all gainful employment”
“disabled” = “restricted from required activity”
Disability by payer system
• Canada Disability Pension (CDP)
– Permanent
– Total
– Any job
• Persons with Disabilities of BC (PWD BC)
– Prolonged
– Total
– Re-trainable / partial work supplemental to $800.00/mo.
• WorkSafe BC
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Gradations to claim and programmatic interventions
Permanent from prior job
Retraining concepts
Pension based on “percentage total body disability”
Maximal Medical Improvement =
• Reached when further formal medical input,
diagnostic testing or treatment, is no longer
expected to have a favourable effect on
patient outcome
• Does not mean the patient’s symptoms have
completely resolved
• State whether or not patient’s condition is
likely to be chronic or permanent
• Most payers are justifiably searching for
“Medical Closure” – be clear.
Handicap /
Participation
Restriction
• A patient may be medically able to seek
alternate employment, but return to work may
be problematic due to societal factors
• Employer won’t rehire until patient is “100%”
• Patient’s age is often a barrier
• Language – especially ESL
• Rural / remote communities, lack of employers
• Small employer unable to accommodate “light”
job
Prosthetics, Orthotics,
and Assistive Devices
Role of rest, exercise, and spirit
• Rest
– very specific to injury tissue and recovery for that lesion
– Targeted “rest” of the lesion only
• Assistive devices, braces
• Ambulatory aides
– Walkers . . . Crutches . . . Canes . . .
• Restorative exercise
– Not just any exercise, specific to the lesion and its domino
• Spirit
– Anxiety and depression assess and treat
– Resources
• Arthur’s Story https://www.youtube.com/watch?v=qX9FSZJu448
• myfitnesspal.com
A Comprehensive Fall Prevention Plan
Education
Environment
Assessment
Equipment
Exercise
Newton’s laws:
Risk Factors
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Lower body weakness
Problems with gait and balance
Reduced sight and hearing
Reduced muscle strength,
coordination, and neurologic
reflexes
Urinary dyscontrol, nocturia
Multiple medical conditions
4 or more medications
Psychoactive medications
Environmental fall hazards
 History of falls**
The Role of the
Family Practitioner?
• In a key position to prevent falls
• Assessment of physical function:
– Basic level
• Rises from chair without using arms
– TUG “time to up and go”
• Step length at least twice foot length
• Walks without assistive device
– Timed walk (30 m < 30 sec)
– High Level
• Tandem walks at least four to five steps
• Descends stairs step-over-step
• Categories
– Frail: fails basic level
– Transitional: passes basic level, fails high level
– Vigorous: passes high level
Supported standing toe rises
Basic squat
Hip abduction
Hams curls
Glut extensions
Geriatric exercise = exercise
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Range of motion
Progressive resistance
Balance and coordination
Cardio but short / intense blast
Embed in functional activities
Socially and community connected
Story of the LOL who could stork-stand indefinitely
Medications
• Patients taking benzodiazepines are 70% more
likely to fall than those not taking these
medications (Passaro et al., 2000)
• Medication reviews were associated with a
significant reduction in falls in a psychiatric hospital
(Murdock et al., 1998)
• Psychotropic drug withdrawal has been associated
with a reduction in falls in other settings but
compliance is problematic
• For patients with a diagnosis of osteoporosis,
bisphosphonates have been shown to reduce
fracture rates
Nutrition
• Poor nutrition is associated with weak muscles
and low bone density, putting older people at
greater risk of falling and sustaining a fracture
• Studies show that approximately 16% of older
people admitted to hospital are severely
malnourished – many with Vitamin D deficiency
• Vitamin D and calcium supplementation have
been shown to reduce fractures in residential
settings and should be considered in hospital
settings
Why hip protectors
• Shields placed
against the
unprotected hip
• Energy absorbing
• Energy shunting:
disperse impact
across a wider area
(Lips & Ooms, 2000)
• Contains a falls
section
• User friendly
and easy to
read
RESIDENTIAL FALLS PREVENTION: STRATEGIES & SOLUTIONS
Challenge
What Staff Can Do
Acknowledgements
Funding for this pamphlet was provided by the Population Health Planning and Support Unit
(PHPSU).
A special thanks to the staff and management at Ponderosa Lodge whose support,
encouragement and dedication made this program a reality.
Rhonda Chisholm, O.T.
Charge Occupational Therapist
Royal Inland Hospital, Home and Community Care
Kamloops
• https://www.youtube.com/watch?v=qX9FSZJu448
Driving – “the gut test”
• Department of Motor Vehicles “red book”
• Sections:
– Vision
– Seizures
– Motor control
• Reaction times
• Sedation / Medications
• Driving assessments options:
– “Senior’s check”
– Mandatory road test
– Driver rehab programs (have licensed pulled)
• Insight Driving Assessment, Vernon
• GF Strong Driving assessment unit
Adapted driving:
• Any alteration or adaptation must be DMV cleared
• Very specific list of “no’s” for Class 1 – 4
• Pilots, military, police – all have specific rules
Lawyers and the IME
• IME = Independent Medical
Examination
• Or “Medical Examination by NonTreating Physicians”
• Legal, financial or insurance reasons
• CONSENT
• Examination
Medical Legal Report
• Reason for IME referral
• CERTIFICATION: Pursuant to the BC Rules of Court, July 1,
2010, Sub rule 11-2(1): I am aware of my duty to the court as an
expert witness and hereby certify that I have a duty to assist the
Court and not be an advocate for any party. I confirm that I have
prepared this report in conformity with that duty. If called upon to
give oral or written testimony at trial, I certify that I shall give my
testimony in conformity with that duty.
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Documentation of consent
Documents reviewed
Hx PMH Soc/Voc hx
Px (objective physical findings, or lack of findings)
Causality
Objectivity
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Be objective
Evidence-based
References where indicated
Humble
Clear
Don’t own the patient – avoid “sides”
• Don’t refer for unnecessary tests or programs
• Say what you can say
• Say what no one can say