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Interdisciplinary Geriatric Assessment:
Mr. Ames

Home Health Treatment

Mr. Ames was discharged to his home after 6 weeks at the rehabilitation center. During his last week at the rehabilitation center he experienced a temporary loss of coordination of his right hand and a short spell of slurred speech. He was referred to a neurologist who ordered a Doppler flow study of the carotid arteries and MRI examinations of the brain and cerebral vessels. Results of these tests showed moderate atherosclerotic disease of the right carotid artery (50 - 79% occlusion) and mild atherosclerotic disease of the left carotid artery (20 - 49% occlusion). There was evidence of chronic small vessel ischemic disease, cortical atrophy, ischemic plaques in the pons, and an incomplete Circle of Willis, all of which are risk factors for cognitive impairments. It appeared that Mr. Ames had a transient ischemic attack (TIA). It was determined he would continue to take one aspirin/day and immediately contact his physician to report any reoccurrence following discharge from the rehabilitation facility.

Upon discharge from the rehabilitation center he was tolerating weight bearing on his prosthesis for less than 30 minutes. Using a roller walker Mr. Ames could ambulate independently for less than 20 feet before having to rest secondary to shortness of breath and fatigue. In addition, the long-term effect of his poorly-controlled diabetes had resulted in diminished vision, sensation and reflexes, magnifying his fall risk. He was independent in bathing and clothing management following setup. Mr. Ames' father-in-law had agreed to spend nights with Mr. Ames to allow Mrs. Ames to continue to work as a night manager in a discount store. By continuing to work nights Mrs. Ames could be available to assist Mr. Ames during the day as needed and take him to his frequent medical appointments. Mr. Ames was discharged with a referral for home health services including skilled nursing, PT, OT, RT, and social work.

Treatment Plans

Following the initial visit by all home health services, the Interdisciplinary Geriatric Assessment (IGA) team met to develop a plan of action for Mr. Ames. (Print the IGA form (pdf) and use the following information to help fill it out.)

Nursing

Skilled nursing will coordinate care including medication compliance, monitoring vital signs, skin integrity, GI, GU, cognition and musculoskeletal status and provide patient and family education.

Physical Therapy

Physical therapy will be concerned with maintaining his mobility, particularly use of the prosthesis. He needs a variety of stump socks of different thicknesses to give him options for getting the prosthesis on immediately when he gets out of bed in the morning. It should be all right for him to remove the prosthesis in the afternoon for rest, but he should wrap the residual limb with an Ace® wrap and elevate the leg a few inches to keep the swelling down. His home was inspected in conjunction with OT and we had a few suggestions.

We are concerned about his endurance. He may need supplementary oxygen to be functional at home. We need to try to keep him on a graduated exercise program of walking or arm ergometer. We can provide a chart where he can check off the exercises he does each day.

Mrs. Ames needs the opportunity to express her concerns, including how to take care of herself. If she works nights and does care giving during the day, she may break down physically or emotionally.

Occupational Therapy

Mr. Ames house has accessible features because when the Ames built the house his mother-in-law resided with them and she used a wheelchair. The hallways and doorways are accessible widths and there are grab bars in the tub and toilet area that are functional for Mr. Ames. The occupational therapy plan includes instruction in use of bathroom equipment safely; e.g. tub seat and long-handled brush. A hand-held shower has been installed also. Recommendations have been provided for improved lighting in the hallway and bathroom and for rearranging the furniture in the living room, kitchen, and bedroom for easier pathways to decrease potential for falls.

The goal is for Mr. Ames to be able to function safely within the home while his wife is working and to decrease her care giving responsibilities. Memory aids will be developed to assist in Mr. Ames following a daily routine and assist with his insulin and medication schedule. He will be participating in a hot meals program and his ability to manage simple meal preparation safely will be addressed. A kitchen stool has been recommended for energy conservation and fall safety. He also will be provided with eating utensils with enlarged handles to compensate for his decreased grasp and peripheral neuropathy in his right hand.

He has expressed interest in continuing his tomato gardening and learning to use the computer purchased by his family to pursue his interest in genealogy. The computer will be modified for his low vision and his minimal coordination problems. Recommendations have been provided for establishing a gardening area on the sun porch, including raised planters, seating bench, and long-handled tools. These activities will provide structure to his routine and a sense of competence.

The driving evaluation scheduled his last week in rehabilitation services was postponed due to his neurological episode. It is unlikely it will occur now.

Respiratory Therapy

Mrs. Ames arranged for the company providing respiratory therapy services to setup, monitor, and maintain the home CPAP equipment for Mr. Ames. Home therapy using a nasal mask with a +10 setting with humidification was initiated his first night at home.

Health Psychology & Social Services

Mr. Ames appears to be coping well since his discharge to his home. He denies current anxiety or depression. Home health care providers are encouraged to monitor his mood and refer to psychological services if increased difficulties are observed. Given ongoing concerns regarding memory difficulties, a referral for neuropsychological testing is recommended. This will provide information regarding his strengths and weaknesses which will be useful for OT interventions.

In addition to services for Mr. Ames, Mrs. Ames will be referred to support groups for family members of individuals experiencing cognitive/physical decline. Two resources are the Alzheimer's Association, even though Mr. Ames does not necessarily have Alzheimer's disease, and the Missouri Department of Health and Senior Services, which can provide support and refer to other relevant agencies.

Does referral need to be made for any other services?

What plan of action for home health would the IGA team develop?

Pause here and fill out your IGA form and compare it to the IGA form filled out by our team.