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Interdisciplinary Geriatric Assessment:
Mr. Ames

Preparation for discharge

Mr. Ames has received 4 weeks of treatment at the rehabilitation center. He has actively participated in all rehabilitation services offered. The team will now meet to discuss discharge in approximately 2 weeks.

During the meeting you will act as the team leader and fill in the IGA form (pdf) to develop the action plan for Mr. Ames.

Occupational Therapy

Mr. Ames is independent in dressing and bathing using adaptive devices. He is exhibiting subtle memory deficits and requires cuing to retain sequencing in tasks. He is able to problem-solve during functional tasks. His endurance has improved and he is incorporating rest breaks regularly in ADL tasks but not in more complex tasks such as simple meal preparation and light laundry. The plan is to increase his participation times gradually. Increased competence in ADLs, especially toileting and mobility, will increase his confidence and decrease his fear of falling. Several low vision devices will be introduced to assist with activities requiring reading, including large numbers for a medication box and insulin monitoring.

Mr. Ames has expressed his intent to return to driving when he has more endurance. A driving evaluation will be scheduled prior to discharge to assess his capabilities and to obtain recommendations for future driving potential and for hand controls.

A home evaluation with PT will be scheduled to assess accessibility and safety prior to discharge and provide recommendations for the home health team. Recommendations should be provided for home modifications and assistive devices that will enhance his vision, decrease risk of falls, and address other safety issues such as thermal burns (bathing, kitchen).

Following his discharge from rehabilitation services, Mr. Ames should receive OT in his home with emphasis on patient / caregiver training on those functional activities that have been identified as priority for him remaining safely in the home.

The cognitive issues especially in the area of memory should be addressed. A plan should be developed for memory assists such as reminder signs, simplified procedures, and emergency procedures like a lifeline device. Part of the home program should include establishing a routine that provides for cognitive stimulation through leisure and home tasks. This would increase Mr. Ames' sense of adequacy and decrease his anxiety.

Physical Therapy

Mr. Ames has engaged in a progressive program consisting of balance, strength, range of motion exercises, and prosthetic gait training. He is presently able to walk 30 feet 2x, with a ten minute rest in between, using a roller walker, the temporary prosthesis and standby assistance. He is able to stand and sit from bed, toilet, and wheelchair with standby assist. He is able to don the prosthesis with set-up. He can identify pressure areas on the stump after walking, and complains about itching when the socket is on, particularly when he is sitting. We will try different stump socks to go inside the socket liner. The stump shrinker does not seem to be doing the job, so he is starting to wear the socket liner even when the prosthesis is off. Mr. Ames has difficulty inspecting the left foot, but the pressure relief shoe appears to be a good fit as there are no noticeable pressure areas after he has practiced gait training.

Mr. Ames should be followed at home by PT to continue amputee gait training as well as endurance, flexibility, and selected strengthening exercises. A home evaluation with OT should be scheduled. He should continue to use the roller walker at home, but may be able to graduate to a cane after he receives his permanent prosthesis.

Health Psychology

Mr. Ames was seen by the psychologist 2 to 3 times per week since his admission. Therapy focused on helping him cope with the frustration he experiences associated with his physical limitations. Mr. Ames also reported feeling anxious about returning home and his continued need for assistance. Mrs. Ames also participated in therapy on several occasions, and she acknowledged her concerns about her husband as well as her distress regarding the responsibilities she has taken on due to his medical issues.

Social Services

Mrs. Ames has visited at least 3 times per week during his time at the facility. She has expressed doubts as to how they will manage if Mr. Ames returns home and is not at least independent with the use of a walker. Mr. and Mrs. Ames have met with the social worker 4 times to discuss discharge options. To make life as easy as possible for his wife, he wants all arrangements for needed support services to be in place prior to his return home. Mr. Ames has expressed his belief that he is ready to return to his home and would like to do so within the next 2 weeks. He would prefer not to go to a nursing home, but would do so to preserve the health of his spouse.

As soon as a discharge date is established, the social worker will contact the support agencies in the Ames' community for home health, homemaker, respite, hot meals and senior companion services.

Nursing

The nursing staff are working with Mr. Ames on managing his diabetes and his diet. He requires supervision with testing and administering his medications and adherence to the time frames needed to manage his diabetes. He can be easily frustrated when he attempts his diabetes management alone. The presence of another person reassures him and keeps his anxiety in check. Mrs. Ames competently assists him with managing his diabetes and his other medications.

He denies phantom or incisional pain. His medication for pain is now on a prn basis. The nursing staff have instructed Mr. Ames in stump and skin care, left foot care, and activities to decrease lower extremity edema and increase circulation. When performing transfers and toileting in his room he prefers to have someone with him due to his fear of falling.

Podiatry

Mr. Ames' toenails were trimmed a week ago. The left great toe ulcer has closed with very delicate skin. He has had his left pressure relief shoe for 10 days, and it fits well. He started wearing it no more than two hours a day, and is now up to four hours a day. He has been instructed to wear a white cotton sock on the left foot.

Respiratory Therapy

The results of Mr. Ames' polysomnography testing supported a diagnosis of obstructive sleep apnea (OSA) and he was referred to Respiratory Therapy Services for Continuous Positive Airway Pressure (CPAP) therapy. CPAP therapy using a nasal mask with a +10 setting with humidification was initiated. The Respiratory Therapist has been working with Mr. Ames to increase his compliance with the CPAP therapy at night. He is wearing his nasal mask with the CPAP +10 a minimum of 6 hours during sleep. Mr. Ames reports he sleeps better and feels less tired during the day when he uses the CPAP. Mrs. Ames has also received instruction and practice in the use and maintenance of the device in preparation for his discharge to his home. Mr. and Mrs. Ames indicate an understanding that for him to receive maximum benefit, use of the CPAP will need to be part of his bedtime routine for the rest of this life.

Prosthetics & Orthotics

Mr. Ames was fitted with a temporary right B/K prosthesis and a diabetic pressure relief shoe on the left. He is not comfortable with the stump sock, reporting his stump itches when he wears it inside the prosthesis liner. We will try a different sock, and if he still has trouble, he may need to change the type of soap, laundry detergent, lotion, or powder being used. To keep his residual limb from swelling, we are starting to keep his prosthesis liner on the stump while he is in bed.

Conclusion of the Team Meeting

When you have completed the IGA form including the plan of action, compare your IGA form to the one developed by our team (pdf).