H&P/ SOAP notes:
Journal Article and Summary:
This articles was a systematic review and meta-analysis that aimed at evaluating the effectiveness of occupational therapy (OT) at home for patients with dementia and their performance on activities of daily living (ADLs), behavioral and psychological symptoms of dementia (BSPD), and quality of living (QOL). In patients with Dementia, Nonpharmacological strategies are recommended as first-line treatment, but it is unclear as to what is effective. Patients with dementia, more so Alzheimer’s disease (AD) slowly decrease their ability to perform activities of daily living (ADLs), and this puts a strain on their quality of life and the QOL of their caregivers.
Management and interventions for Dementia include trying to maintain independence of ones ADLs, which is why the authors looked into home OT as an intervention. The authors screened 9737 articles and found 15 eligible studies, which includes a total of 2036 patients. The RCTs that were examined were conducted in many countries including USA, Germany, Hong Kong, Wales, Australia, Brazil, and the Netherlands. It was comprised of mostly patients with moderate dementia, whose majority age was over 75, a MMSE of 11.3 to 22.73, and all requiring assistance with ADLs.
The results showed that meta analysis of five studies found OT to be more effective than usual care or attention control in improving ADLs. Also seven studies had measured QOL, which reveled significantly better QOL than control groups. Limitations and weaknesses of this study include blinding of participants and therapists in studies could not be achieved, but this is usual of many non-pharmacological interventions. Expectation bias could exist which can lead to overestimation of results. Also they had identified a number of trials but were unable to perform a Meta analysis due to the data not being in suitable format or different comparison groups.
OT has showed to delay functional decline and by focusing just on OT provided in the home and examining a broader range of outcomes, this review may be more informative for primary care providers and for health professionals within the hospital system referring on to community-based care. So patients with moderate stage dementia receiving OT at home for at least 8 sessions, had improvements in their outcome measurements like ADLs. Patients were better at carrying out ADLs, IADLs, less behavioral symptoms, and a better QOL.
Site Evaluation Presentation Summary:
At my last site evaluation with Dr. Davidson, we went over DTRs and other reflex/signs such as the glabellar, snout, Hoffman, and tromner sign. Additionally we spoke about herbals and alternative medicine that a patient was taking to prevent/slow the progression of AD, such as Gotu Kola, Shilajit, and Black seed oil.
During this site evaluation I presented a 72 y/o African American veteran Male with a 35-pack year smoking history who recently quit and PMH of NSTEMI, Dementia, HFrEF, HTN, HLD, and OA of Knees b/l. Pt was last seen at ADHC in 02/03/2020 c/o n/v/SOB. He was noted to be tachycardic followed by a syncopal episode, code was called, and 911 arrived, found to have wide complex tachycardia/ Vtach. He received shock x 1 and converted to NSR. He was then taken to Jamaica Hospital ER and transferred to Manhattan VA CCU on 02/05/2020. Discharged from hospital on 02/14/2020 and received a BiV ICD on 02/10/2020. We spoke about his discharge plans and how his current condition was. It wasn’t quite clear as to his need for a walker, besides having OA of both knees and a slow gait.
Overall she commented that the HPI was well presented and well constructed. However I need to make sure all info reported later is present in the HPI or PMH. Dr. Davidson also commented “Good work on specifics of orders and patient education.” She had previously told me to focus on my physical exams as there is more time to do a full/thorough exam with less pressure from providers in LTC. I heeded her advice and practiced completing a motor/cerebellar/sensory exam during the rest of my rotation.
Typhon Log:
Self-Reflection:
My second rotation was at the Veterans Affairs (VA) St. Albans Community Living Center. It was an interesting site as they use to be a hospital but now aims at providing primary care and some subspecialties catered towards the geriatric population along with rehabilitation services. I have heard from previous students before that when you are in your Long Term Care (LTC) rotation you would be mostly practicing on writing H&Ps, and for the most part they were right. I would normally see 1-2 patients in the Adult Day Health Center (ADHC) and complete a full H&P along with a monthly template. However I was fortunate to have a thoughtful preceptor, Mrs. Myers who gave me autonomy along with exposure to different clinics. I participated in the vascular and urology clinic a handful of times. Additionally I was able to partake in the lab numerous times and practice venipuncture’s technique on veterans and staff. This was most helpful and gave me confidence for my future rotations.
I was very ecstatic that I was able to get exposure in urology since our program does not have electives or a urology rotation. I learned a lot from the urologist, Dr. Weiss as he was very friendly and a good educator. I saw a variety of cases from erectile dysfunction, BPH, overactive bladder to hydroceles and renal carcinomas.
For this rotation I was asked to lead two separate group exercise/stretch sessions, and also give a presentation on the COVID-19 virus for the elderly. The first time I was asked to do the group exercise/stretch session it was spontaneous and I was thrown into it as the ADHC had no recreational therapist that morning and needed an activity for the attendees. I was nervous at first but thought back to the time when I was teaching tennis to children and young adults. I attempted a few easy stretches and even asked them to stand and do static exercises, but soon realized that the target population was different. The participants joked about who would be catching them if they fell and if I was going to make them do push ups. I recognized that I was leading a group of patients with limited range of motion, some wheelchair bound, and most with decreased strength. So instead my preceptor advised to work on breathing exercises and some chair stretches. Needless to say it was a long 45 minutes and I was getting more of a sweat than the patients. Afterwards I felt that it is always important to be cognizant of who your patient population is. I also felt I could do better so offered to lead another group, which I did the following week. This time I was able to do some research and watch exercise/stretch videos geared towards seniors. I planned a whole 45-60 minute yoga and seated/standing exercise and stretch session. I even played some calm, soothing yoga tracks on a mini speaker I brought in. I felt much better prepared and the session was a success as everyone enjoyed it and they got a good workout.
The COVID-19 presentation was enjoyable as I was able to practice my presentation and public speaking skills. I catered it towards the senior population and included videos and demonstrations on hand washing. I created a COVID-19 Presentation PowerPoint and a handout packet for them to go over with their families and caregiver at home. It was the basic facts from the CDC and WHO as I recognized a lot of the patients were intelligible about the topic, even more so than myself as they watch/read the news daily. I succeeded in making the presentation more interactive and an open friendly conversation. They enjoyed the entire dialogue and appreciated someone addressing their questions. My preceptor enjoyed it so much that she asked for the video resources and wanted to include future educational presentations in rotations.
Overall this rotation gives me a deeper appreciation for the elderly population. As most of us have grandparents and parents who are older or getting older. Sometimes it can be hard to see elderly patients being neglected or “dumped off.” However the VA was a great facility and its great to see veterans being taken care of after serving our country. I also have a greater appreciation for caregivers as the elderly can really test their patience especially those who have cognitive impairment.
One of the things I would like to continue improving on is the ability to formulate a treatment plan immediately after the visit. My notes would usually be delayed because I would always want them checked by the preceptor to see if it was appropriate or to discuss what the next best treatment would be. I believe that I can improve upon this by studying more on the treatment plans and utilizing UpToDate as a resource for treatment options. I know that the PANCE and EORs also like to test on treatment so it is vital that I can incorporate this into my studies.
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
