Suggestions

Permission for Use

Interdisciplinary Geriatric Assessment:
Mr. Ames

Termination to Family & Community

Approximately 5 weeks following discharge from the rehabilitation center Mr. Ames informed the PT that he is frequently frustrated by the difficulty of ambulating since his amputation. His low tolerance for physical activity also bothers him. He is concerned for his wife and the heavy physical demands his illness puts on her, to work nights and then be available to assist him during the day. He reported that their children have continued to come stay with them with the same frequency (2 to 3 weekends a month). When they are present, it eases the burden of his wife's being totally responsible for him. Mr. Ames is nearing maximum benefit from his therapies and both OT and PT will be discontinued in about 2 weeks.

Mrs. Ames has expressed to the OT her concerns that Mr. Ames is forgetting things that were once important to him such as when he last spoke on the telephone with his children. After assessing the adequacy of the memory aids it was decided to also utilize an auditory reminder system because Mrs. Ames is concerned he will not take his medications and eat if not reminded. The last few days she has also become more concerned about how safe he is home alone for more than an hour or two. She came home from work one day last week and found him lying on his side on the floor between the commode and the bathtub. He reported to her that he really couldn't recall what he was attempting to do, but he was glad to see her when she entered the room. It was decided that Mr. Ames should be equipped with an emergency assistance personal alert device.

Instructions and safety education for the respite and companion personnel have been provided to Mrs. Ames. Arrangements for these persons have been made when home health services are terminated.

Mr. Ames' endurance has increased and he has demonstrated the ability to employ energy conservation strategies in using stools in the kitchen and porch. He is independent in ADLs using adaptive devices. Mr. Ames is using his CPAP machine for 4 to 5 hours per night. The Ames have established a positive working relationship with the local company providing the CPAP equipment, and they will continue to provide follow up and maintenance in the home.

Mrs. Ames is experiencing severe fatigue from her overburdened schedule. She scored in the moderate range on the Caregiver Strain Index and Caregiver Burden Scale. Recommendations have been provided to her for counseling services. She has been encouraged to use the support of her minister and church group.

The MSW has made arrangements for in-home companion services three times a week to allow Mrs. Ames uninterrupted sleep or time away from home, during the day and respite services three times per week to allow Mr. Ames' father-in-law to sleep in his own home. These services will be starting immediately to relieve caregiver stress for the family. Instructions and safety education for the respite and companion personnel have been provided.

Some relevant links are:

American Sleep Apnea Association
Family Caregiver Alliance
National Family Caregivers Association
National Family Caregiver Support Program
Other caregiving resources

The IGA team will meet one more time to develop a specific plan. Act as the team leader for the virtual team to develop an action plan.

Pause here to fill out your IGA form (pdf).

You may also be interested in similar cases:

Interdisciplinary Geriatric Assessment: Mrs Curtis
Interdisciplinary Geriatric Assessment: Mr Fine
Interdisciplinary Geriatric Assessment: Mrs Kell