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Elderly Couple Eating



-written by Bikram Mohanty OTR/L.

published in advance for Directors of Rehabilitation

    Have you ever forgotten your car keys or misplaced your glasses? Everyone experiences these memory lapses from time to time. In most instances, it's merely a case of absent-mindedness. But forgetfulness may be one of the indicators of something more severe for elderly people, namely dementia.

   For many health care workers, family members, physicians and researchers, dementia is poorly understood. Dementia is neither a disease nor a diagnosis; it's a term for a collection of symptoms. Due to its nature of inconsistent symptoms among people, management is always a complex issue. 

   Clinicians do know that dementia is a progressive impairment of orientation, memory, judgment and other aspects of intellectual functioning. Characterized by generalized cerebral atrophy, dementia can be more prominent in the frontal occipital temporal regions of the brain. Histologically, it's characterized by neurofibrillary tangles and senile plaques. 

   Working with Clients who have dementia can be difficult, particularly in cases of severe dementia. Many of these residents can't even follow commands or make eye contact. Nevertheless, you must still conduct an evaluation to determine impairment levels, then teach coping skills and strategies to compensate for mental deficiencies. This evaluation allows you to establish a performance baseline for later comparison, identify specific traits or behavior patterns and gather data to design a treatment plan. This process should include the following steps:

  • Testing: Standardized tests are a valuable resource for gathering data. The success of standardized tests, however, depends on the type of instrument you choose and a client's level of cognitive ability. Options include, Kohlman's evaluation of living skills (KELS), functional assessment staging (FAST) and Allen's cognitive level (ACL) test. KELS and FAST focus on determining a patient's functional ability and disability, based on cognitive function. Allen's cognitive level also can be used to classify functional stages of the patient. Another test--the global deterioration scale--helps determine the level of impairment. It's useful to measure future impairment and give caregivers an idea what to expect as the disease progresses. If a client can participate or follow directions to complete a standardized tests, consider similar options. For instance, the mini-mental test is a short verbal questionnaire that determines quantitative measures of cognitive performance. To obtain information and identify functional deficits, you also can ask informal questions, interview caregivers or review medical records. 
  • Observation: Observe the patient to obtain vital clues about cognitive function. Can a resident recognize simple objects, such as a toothbrush or spoon? Does he know his immediate living environment and potential hazards? Does he know his body parts? (In late stages of dementia residents don't). Questions or criteria should progress from simple to complex activities. For example, see if a person remembers his room number first before asking if he can recall a longer series of figures in a telephone number. 
  • Record review: Records from other clinicians or former care facilities are important resources to determine functional or cognitive impairments. Let's say documentation indicates that the patient was agitated when it was time for breakfast. Before labeling the patient as having behavioral problems, examine life-long habits as documented in medical records. Maybe the resident isn't an early riser or only likes coffee in the morning. He may not be exhibiting problem behavior; he's just not interested in breakfast and is irritable in the morning. After a complete evaluation, you'll have a better understanding of the resident's abilities and potential to handle functional tasks and activities of daily living. Of these tasks and ADL's, self-care is particularly difficult with residents who have dementia. Nevertheless, strategies--as the following scenarios illustrate--can help caregivers manage the problem. 

Problem 1: A resident can't attend to dressing tasks. The inability to initiate or tend to the task is a common symptom in people with middle-to-late-stage dementia. At these stages, the client's cognitive ability to process the information is impaired or lost. Sometimes, the ability to process the information only partially exists, and the resident doesn't understand an activity's benefit. Moreover, fear may underlie some of the behavior. For example, the resident may be afraid of falling when he tries to put on clothes.

Solution: Simplify the closet. Hang only a few pairs of clothes and limit choices. Too many choices frustrates the client. Be familiar with a resident's dressing habits and styles. For instance, if someone loves to wear suspenders, he may not remember to connect pants and a shirt to wear the suspenders. Handle the problem by making sure the suspenders are always attached to the pants before he puts them on. Talk to the family or other caregivers about dressing style and favorite items, such as ties, coats or jewelry. In addition, don't tell the client that his choice is wrong, which could cause anger or irritation. Instead, respond diplomatically by saying, "I think this shirt would look nice on you."

Problem 2: The resident can't participate in bathing. Some residents don't understand the need to bathe. In addition, some may be afraid of the water. Others may feel embarrassed and may, therefore, say they've already showered.

Solution: Lifelong habits that rely on time play an important role. If a client lived on a farm and was an early riser, it will be difficult or impossible to persuade him to shower at 11 a.m. Design the patient's schedule so he can bathe early in the morning. If embarrassment is an issue with bed bath, start by washing the face, then both arms. Go slowly and don't rush the resident. And never insist that the patient undress. Make the shower warm and comparable to home bathing. If fear of hot water persists, try using a warm towel or wash cloth. Don't direct a hand-held shower or take the resident under the shower, which can heighten anxiety or fear. To soothe the patient, consider signing a favorite old-time song during bath activities. 

Problem 3. The resident refuses to participate in mouth care. Some residents may have lost the ability to understand the importance of personal hygiene.

Solution: Break down the task into small components. Start by opening the toothpaste and apply it to the toothbrush. If the resident doesn't recognize the items, use general labels such as "toothbrush," not brand names. With dementia, the brain can recognize general terms, but can't connect the concept of a brand name with a product. If the patient still rejects the mouth care, you can use mouthwash or swabs for hygienic purposes. 

Problem 4: The resident has difficulty attending to eating tasks. He has problems initiating the tasks of scooping food or picking up a glass, secondary to impaired strength and motor control.

Solution: Make sure residents haven't been under-stimulated or overstimulated before mealtime. If overstimulated mentally or physically, a resident may not be able to initiate the task of eating, either because he's exhausted or he thinks he's already eaten. And if under-stimulated, the patient might think it's still morning, even though it's time to eat lunch. As a result, he'll refuse to eat. If the client still comprehends the importance of money, you can provide tokens to create the impression that he's paying for the meal. This exchange allows the resident to feel as if he has some control. But don't offer too many choices of foods, it will only create confusion. However, a facility should change the menu periodically to keep patients interested in mealtime. Boredom can set in if patients eat the same foods everyday. Introduce finger food if the client has trouble using utensils. In addition, try to maintain uniformity at the dinner table by placing residents with similar abilities together. And creating a pleasant atmosphere--such as the smell of barbecue wafting through the air--stimulates the desire to eat.

Caring for older adults with dementia is a complex task for health care clinicians and caregivers. By applying these successful coping strategies, however, you may be able to lessen the complexity of care. 

Don't take our word on it... take their word.... 

Valdosta Daily Times Article

Talking to several patients at Innovative Rehab Solutions in Valdosta is a humbling experience. Speaking with individuals who are working hard to overcome physical and medical issues could easily be overwhelming, but when they have tremendous spirits and positive attitudes, it's also uplifting and inspiring. Bikram Mohanty, occupational therapist walks us through some of the therapies offered but otherwise, stayed in the background and let their patients tell the story.

--written by Kay Harris of VDT

published in The Valdosdta Daily Times

Scuba Diving

Recovering from paralysis:

For Laurie Miller, Innovative Rehab is a lifeline back to a normal life. On Nov. 30, 2010, Miller developed symptoms of severe Transverse Myelitis. In four hours, she was paralyzed from the middle of her back down. In Tifton at the time, she sought medical treatment immediately and was diagnosed quickly, with steroid therapy helping her regain movement. Transverse Myelitis is an inflammation around the spinal cord which damages nerve fibers. Causes range from viral infections to complications of a disease or even a vaccination, but in a number of cases, there is no known cause. These causes are called idiopathic, which is what Miller is experiencing. 

"One thirtd of patients have no recovery at all, one third have a partrial recovery, and one third have a complete recovery," Miller said, who is still undergoing treatment three years later. 

After undergoing treatment at several facilities, she moved to Valdosta and found Mohanty. She immediately felt at home, and began therapy which included using the underwater treadmill. 

"It works just like a treadmill but you have the pull of the water, so it's much gentler but more effective. You can set the speed, time and resistance, and I work out with weights in the water. too," she said. 

Miller also under goes CTS, or craniosacral therapy, with Mohanty.

"It's a type of massage, except Mohanty barely touches me. The touch is so gentle you can hardly feel it. It helps to balance your systems by gently manipulating the body's pulse points, and it makes me feel totally relaxed," she said. Mohanty said that CST not only can help heal the body, it can also help to build immunity and be used as a preventive tool. 

"For example, if a patient has had a mini-stroke, the therapy can help prevent the chances of having another stroke," he said.

Although Miller has made significant strides in her recovery process, she has a long road ahead. She has loss of feeling in her legs. She can walk, but recently walked into an ant bed and had no idea that she'd been bitten until hours later, and by then, the bites were becoming infected. She has problems with balance, but after working with Innovative Rehab, she says she falls less than she used to and can catch herself now. The main issue for Miller in recovery was getting to scuba dive again. 

"I went to Key West and I dove!" she said. "I dive shipwrecks and it was wonderful to get back to it."

Family Sitting

A child's battle:

Halia Strickland is a vivacious 10-year old who's not afraid to tell you her opinion, especially when it comes to medicine. 

"Awful!" she says, when discussing the chemotherapy or the many pills she's had to take in the last five years. Elena Strickland, Halia's mother, said up until four years ago, she was a very healthy child. However, in August of 2009, when Halia was 6, her fingertips turned blue, a condition called Raynauds' Syndrome.

"We took her to her pediatrician, and he didn't know what was causing it. He started her on steroids but a couple of months later, her fingertips became necrotic and they fell off," said Elena. After taking Halia to numerous physicians and spending several weeks at the Medical College of Georgia facility in Augusta, she was ultimately diagnosed with Schleroderma, a chronic disease; its most visible symptom is hardening of the skin. 

"The disease is progressive, and as her skin hardened, it was drawing up her arms and legs. She has to have therapy so she can move and stretch," Elena said. "If she didn't have therapy, she'd get much worse and her skin would get tighter." The aquatic therapy in the pool is Halia's favorite part as she said it feels good and relaxes her and she loves the staff at Innovative Rehab. Halia's father, Michael said she has been to several therapists, but Mohanty has been the best for her and the family owes him a great deal. 

"The water therapy really helps her, and even when Medicaid said they were going to reduce the number of visits she was allowed, he kept treating her because he really cares about her well-being," Michael said.

Elena said other therapists were much rougher on Halia but Mohanty is very gentle. "She's never been uncomfortable coming here, even when she's hurting." Elena said. "He does what she needs and will benefit her, not just what Medicaid will pay for." Scleroderma is a lifelong condition but she could stabilize, get worse or get better. According to her mother, Halia has a 5 percent chance that it could go away completely. Micheal and Elena are homeschooling Halia and her sister, Katie, 11. Both are at the sixth-grade level as Halia has skipped the 5th grade. Both parents work and share homeschooling duties, with Michael smiling and referring to Elana as the "principal."

She has been so inspired by Bikram Mohanty and the work he's done with Halia that Elena has decided to continue her education and become an occupational therapist, too. He recommended her to a program in Atlanta where she will attend her master's level classes every other weekend so she can be home with her family. 

One of the most challenging aspects of the disease is that Halia has a difficult time gaining weight. "She's gotten taller but she weighs less than she did several years ago. She can eat anything and we encourage her to eat whatever she wants."  Halia's preference? "Anything with sugar in it!" and her favorite food? "Cookie dough or cookies and cream ice cream."


Life can change in a heartbeat:

One moment Matt Dupree of Homerville was a healthy, strapping 20-year-old man. The next moment, his life was forever changed when his ATV hit a culvert on a highway in Homerville. Matt was life-flighted to Shands in Gainesville, Fl, where physicians are trained to work with severe brain injuries. 

"He didn't have hardly a scratch on him. No broken bones. But the doctors said his brain damage was so severe, he would always be a vegetable," said his father Don. As Matt was receiving therapy on a table from Bikram Mohanty, he listened attentively as his father described his life since May 5, 2007. 

"Matt spent 100 days in Shands, and they tried to get us to unplug him twice, but we wouldn't give up." When he asked what would have happened to Matt if they had, Don says, "He would have been sent to a nursing home to die."

After fighting to get him accepted into Shepard Center in Atlanta, which specializes in traumatic brain injuries, Matt spent six months there undergoing therapy. Shepard follows up with the family, and they still visit the center monthly. Following his time there, Don says he and his wife, Cindy, carried Matt everywhere they could get him help. 

"When it's your child, you do what you need to and you keep looking until you find what works." 

Matt was football player for Clinch County on the state championship team, coached by his uncle, Jim Dickerson. For a gifted athlete to not be able to walk, talk or control his movements, life for the Duprees was not easy but they weren't deterred. They kept taking him to different treatments, from acupuncture to horse therapy, and his condition slowly improved, ultimately found Innovative Rehab. 

"Now, he can walk 1,000 steps a day and he swims in the pool. They said he would never talk again and you can see that's not the case at all," said Don, as Matt started chatting with the reporter and the staff.  "He's come a long way working with Bikram, and he has a great attitude. I know he will continue to improve," said Don. 

Even though initially, physicians didn't give the family much hope, after some time at Shands, Don received a call one day from Cindy on his cell phone while he was standing besides Matt's bed. "He reached for the phone. I couldn't believe it. I told his mom to hang on and to talk to him." 

Don said Matt brought the phone up to his ear and talked to her, saying just a few words, but that was more than enough.

"The nurse didn't believe me that he could talk, because when they came in the room and spoke to him, he wouldn't answer them. I told one nurse to go out and call him on the phone, and she did. He answered and told her he was fine. She peeked around the corner because she thought it was me playing a joke on her, and couldn't believe it was him."

8 Myths about Migraines:

Myth #1: If you don't experience AURA, you don't have a migraine. Fact: Truth is only 25% of migraine patients experience a migrine with aura. People who have a migraine with aura, they can have have a migraine without aura as well. Migraines may progress in four stages: prodrome, aura, attack and postdrome. Not everyone experiences all four stages during a migraine. 

Myth #2: Only adults suffer from migraines. Fact: A migraine can happen to anyone at any age. The most common age range is 20-40 years of age. The condition does improve as people get older toward 50's and 60's age range. About 18% of women, 6% of men and 10% of childern suffer from migraines. 

Myth #3: A migraine is only a bad headache.  Fact: A migraine is a neurological disease. A headache is the symptom of the disease. A migraine can happen without the headache, which is called a silent migraine. A migraine i9s characterized by its nature of inheritance. 

Myth #4: Nothing can be done for migraines. A person must learn to live with them. Fact: This is far from the truth. It is a fact physicians or therapists cannot treat a migraine. Here at Innovative Rehab, we have  used a proven treatment method called Craniosacral Therapy, AYURVEDA  and aquatic therapy to help eliminate migraines. Also, we can teach you how to prevent a migraine attack. 

Myth #5: A migraine only attacks on one side of the head. Fact: Although headaches on one side of the head are very common, one-third of cases have headaches on both sides of the head. 

Myth #6 Migraine and stroke have nothing to do with each other. Fact: Though inconclusive, risk of stroke has proven high for women 30-40 years of age who have high reoccurances of migraines, are regular smokers and who use birth control pills. Migraneous infarction is the name given to a mini-stroke that happens during a migraine attack. 

Myth #7: Migraine is a disease of the blood vessels or an inflammatory disease. Fact: For a long time migraine was condsidered a disease of the blood vessels or an antiinflammatory issue but recent research  has proven that it is actually a nervous system (brain-related) disorder which depends upon how excitable your brain cells are under certain conditions. (Dr. Zameel Cader and Prfessor Peter J Goadsby. 2011)

Myth #8: Migraines always attack young women. Fact: Before puberty migraines attack more boys than girls but it is true more adult women are victims than men. 

--written by Bikram Mohnaty, OTR/L

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