Assessments: When it comes to evaluating patients, no matter what setting you’re in, standardized assessments are essential in painting a full picture of your patient’s current medical and functional status. Every occupational therapist in every setting should ultimately be using at least one standardized assessment in their therapeutic evaluations.
Balance: It’s no secret that good balance = safety. And even if you’ve never worked with older adults, I’m sure you’re aware that they often exhibit decreased balance both in sitting and standing. Our bodies rely on our musculoskeletal strength and alignment to maintain balance, but they also rely on our vestibular (where is my head in relation to my center of gravity?) and proprioceptive (where is my body in space?) systems. As we age, our muscles tend to atrophy and our bones start to degenerate, and the same is true of our proprioceptive and vestibular systems. Those sensory nerve receptors can atrophy in the same way muscles can. Add on the presence of pathologies like peripheral neuropathy, CVA, dementia, or diabetes, and you’ve got the perfect recipe for a fall. This is why it is so important for us as the OT to stimulate those sensory nerve receptors in order to improve dynamic balance.
Community Reintegration: In the SNF (skilled nursing facility) we generally have two categories of patients: those who are admitted for short-term skilled rehab, and those who are admitted for permanent, long-term care. Which means we have two categories of community: community within the facility, and community outside the facility. As an OT, we can assist with re-integration to both.
Death and Dying: When working in a long-term care setting designed to care for older adults, we sometimes witness drastic medical decline in patients that we closely work with each week. We watch as the life slowly (or sometimes rather quickly) drains away from a patient until suddenly they are gone. A full lifetime is never guaranteed. So no matter what population or demographic you work with, remember that you as the OT are here to help people live well. Our goal is to help our patients, our people, live well. And we do that by loving them well, even up to death.
Environmental Modifications: The environment in which we live can either support our health and well-being or limit it. This is true of anyone at any age. But as we age, our environmental supports become especially important in decreasing fall risk while maximizing functional mobility and independent task performance. As the OT, it is our job to ensure that we have appropriately educated the patient and his/her family on the safest ways to modify the home environment for maximum support.
Fall Prevention: Fall prevention is one of the most important things we focus on within the SNF setting. A fall for an older adult can be debilitating if not fatal, especially in instances where surgical intervention is required in adults who already have progressed dementia. This is why it is so important as the occupational therapist to assess risk for falls in order to ensure the safety of our residents.
Goal Writing: Goal writing is something that took me a long time to appreciate. If I’m being honest, grad school didn’t really give me a love for written goals, but rather a fear of them. But goals are so so important in keeping the patient at the focus of our therapeutic interventions and overall plan of care.
Home: It is always encouraging for a patient and their family to know for certain that the patient will be returning home. But the transition can also be scary and stressful for them. There is always this uncertainty and fear of “I’m not quite ready. What if I fall again. I’m not going to have as many people around to help me at home as I do here.” Of course this is completely understandable but also a fear that we can help the patient to overcome. As with my post about community re-integration, we need to ask the correct questions in order to make sure we are setting the patient up for success at home.
IADL Training: When we talk IADL, we’re talking about meal prep, laundry, housework, money management, medication management, pet care, child care, etc. The realm of IADL can be as broad or as narrow as you want. There are so many fun ways to actively engage IADL task training into our therapeutic sessions.
Joint Protection: Many of the patients I treat on a routine basis have some degree of osteoarthritis throughout their hands. This is why joint protection training is essential in maximizing functional use of the hands while assisting with pain management. A gross grasp is the best way to protect the joints within the hands. This means that we as the OT work to teach the patient to use large, wide grasp patterns when completing daily tasks.
Kitchens: Our gym/therapy space is great but it is relatively small and did not come equipped with a kitchen or ADL/IADL space. So we’ve had to get innovative with the ways that we simulate kitchen and meal prep tasks without the use of a kitchen.
Lower Body Strengthening: While lower body strengthening is usually reserved for PTs, there are still ways that we can functionally incorporate strengthening routines into our sessions from an OT perspective.
Mechanical Lifts: Mechanical lifts are a major part of safe care within the SNF. In our facility we use two mechanical lifts in particular; the stand-lift and the Hoyer. Both are used to safely assist with functional transfers across varying surfaces. If a patient requires at least max assist of 2 for a sit>stand transfer, it is likely time to consider incorporating a mechanical lift. It is important to remember that the stand-lift requires more active engagement from the patient than the Hoyer. Therefore, when determining the appropriateness of a stand-lift versus a Hoyer, it is important to refer to standardized assessments to justify its use for transfers.
Novelty and New Learning: When you have dementia, just about everything seems novel and new. A typical day is filled with new faces, new routines, new environments, and new expectations. So how do we as the OT help these patients adjust to a new routine, environment, and community? The answer: repetition. Studies have shown that new learning can occur in older adults with dementia if the task to learn is repeated 100 times. You read that right; ONE. HUNDRED. TIMES. This sounds like a lot, but it can be done.
O2 Management: Patients who have been hospitalized for COPD exacerbation or pneumonia are great candidates for the SNF. They usually present with muscle weakness and pulmonary weakness, and have a high chance of returning home within a few weeks. This means that we work a lot on pulmonary endurance, muscle endurance, energy conservation, diaphragmatic breathing, and equipment management.
Positioning: Seating and positioning is crucial when attempting to maximize functional performance. When posture is poor, functional performance will be poor. We need appropriate posture for successful toileting, safe self-feeding, independence with wheelchair mobility, and general active participation in the environment. Since many tasks among our long-term residents are performed from a seated position, we often receive referrals for patients who need an improved seating system. This means we deal with positioning a lot in the SNF setting.
Quality over Quantity: We all know that when you work in healthcare you face billing, productivity standards, and insurance regulations. After all, the healthcare profession is a business as well as a service. But the service we provide is to real, human people. People with families, feelings, frustrations, and fears. Remember that the point of OT is to improve quality and function based on the patient’s personal goals. So communicate with your patients. Advocate for them. Educate them. Serve them. Love them.
Routine: Personally, when my routine has a good flow and rhythm and consistency, my days tend to go much better and my mind feels a lot less cluttered. The same is true for many of our residents. Most of them long for routine as much as we do. Often, skilled nursing facilities naturally have a flow and routine to them. But sometimes, it can still be challenging for many of our long-term residents to identify and follow a meaningful routine, especially those residents who exhibit progressed dementia.
Sensory Integration: Sensory processing, in short, is the way in which we as humans use our 7 senses to experience the world around us and in turn regulate our emotions. Diagnoses like dementia can result in a decreased ability to appropriately regulate these emotions, which means that we as the OT can provide specific sensory integration techniques to maximize emotional regulation and overall occupational performance.
Teaching and Training: Transfer training is a huge part of what we do in the SNF. The use of safe and appropriate body mechanics during all transfers is crucial for maximizing both patient and staff safety.
Upper Body Strengthening: Upper body strength is an essential component of functional performance and mobility. Which means that we can easily and functionally incorporate these strengthening routines into our therapeutic plan of care.
Vision: Just like muscle tone, bone density, and vestibular function, vision diminishes as we age. Personally, I have found this to be especially true within the SNF setting. There are many ways that we can work to increase contrast, increase lighting, and decrease clutter within the patient’s environment in order to maximize safety and independence with functional mobility.
Wheelchairs and Walkers: We’ve already talked about how to address posture and positioning as it relates to identifying an appropriate seating system for our patients. So we’re also breaking down the different types of wheelchairs and walkers, and how to know which ones to use/prescribe to our patients.
E ‘X’ cellence: When you work in healthcare, no matter what profession you work in, there will be situations and circumstances that are simply beyond our control. And sometimes this can pose a seeming threat to the flow of our session. But we are trained to easily adapt to any given situation in order to provide the best care for our patients.
You: Therapeutic use of self is the ability to take your own personal experiences, communication styles, emotions, and personality to build a unique therapeutic rapport with your patients. For me, therapeutic use of self is allowing my own experiences to transform how I act and interact with my patients. This doesn’t mean unpacking all of my baggage. It simply means treating patients the way that I hope to be treated as a patient; with honesty and respect and kindness.
Zzz’s (Sleep Hygiene): When working with the dementia population, sleep hygiene can become completely discombobulated. People often sleep all day and are awake all night. But guess what, this is just another area that we as the OT can address therapeutically. This is an area that I have tried to perfect through lots of trial and error. So for our final ABC’s of OT post of the year, I’m highlighting the techniques that I have found to be effective in improving sleep hygiene among older adults.