Occupational Therapy: Who Needs It?

From an interview with Abby Moul, Occupational Therapist, and Director of Rehabilitation at Peninsula del Rey in Daly City.

Here at Dr Liz Geriatrics, we get asked about ‘occupational therapy’ fairly often. This special blog post will answer some of the most common questions we receive. Because this post is a bit longer, you can click on any of the following questions to conveniently ‘snap’ to that section. We hope you find this post helpful and informative!

1. What is Occupational Therapy?
2. Occupational Therapy for Elders
3. How to Get Someone in Pain Out of Bed
4. How Occupational Therapists Help Modify Homes to be Safer
5. What to Do When an Elder Can’t Walk Anymore
6. Are Transport Chairs Safe?
7. Post-Stroke Care From an Occupational Therapist
8. Using a Smart Device to Deal with Poor Compliance in Taking Medications

 What is Occupational Therapy?

Occupational therapy utilizes a holistic approach, so it’s not just about the physical components of the body; it also address the mind and emotional aspects as well. An occupational therapist is focused on helping people to be as independent as possible in their daily activities and to re-engage in life in whatever way they need to. 

The word occupational has its root in ‘occupation,’ which is any way that someone would occupy their time. The term is a bit confusing — some people tend to think, “Oh, you help people find jobs.” They could intervene in that way, but in the geriatric population, it’s mostly helping elders to engage in life at their fullest capacity possible.

Occupational Therapy for Elders

There are a lot of people who work to give elders the best life possible — for example, health coaches. 

However, an occupational therapist, in addition to training, education and health, studies anatomy and physiology which helps them understand the ways in which both the body and mind work.  This enables the occupational therapist to make a detailed assessment of all systems of the body, figure out what areas have problems, and then address those problems in order to help that person achieve their goals.

Those goals could be for an elder to:

1. Get themselves dressed
2. Go to the bathroom
3. Manage their own finances
4. Manage their own medication 

How to Get Someone in Pain Out of Bed

If someone’s been in the hospital for an extended period, if can be difficult to get them out of bed and moving again.

Case Study: Rehabilitation for a bedridden elder

An elder has had a fall. From this incident she now has a compression fracture, is in pain, and is very angry and confused. She’s been left in a nursing home bed for several months without moving because of the pain she was experiencing. They didn’t want to give her pain medication. Additionally, she’d yell at people, so caregivers tried to avoid her as much as possible.

With this patient, Dr Liz accomplished the following:

1. Figured out exactly where the pain was coming from, then eliminated that (neuropathic) pain.
2. Got rid of medications that were making her more agitated, and replaced another medication that was contributing to the agitation: The patient been on Ativan (lorazepam), which is in the same family as Xanax and Klonopin. (It can make a patient more mellow, but elders sometimes get addicted to it; it can then make them more disinhibited and angry)
3. Ultimately, the patient was still bedridden; Dr Liz referred her to an occupational therapist for further rehabilitation.

The Solution: How an Occupational Therapist Helped

Pain management and helping to control that ‘edge’ is critical.  Once a patient is under the optimal combination of medications (controlling both pain and other things that may be going on), an occupational therapist can then have a discussion with the elder and their caregivers about trying different types of therapy. 

From the physiological point of view, an adult can lose 1% of their muscle mass if they’re in bed, and an elder in their 70s, 80s, or 90s can lose 5%. So, if they’re in bed for 10 days, they can lose 50% of their muscle mass!

When an elder has been bedridden for long periods of time, it is important to start slowly with appropriate exercises to help them regain strength and endurance.

Comfort and safety for the elder is critical in these situations, but sometime there can be a barrier. For example, it might be that an elder has a fear of falls.  An occupational therapist can show the elder how to feel safe when it comes to mobility, balance and coordination by showing them:

1. Stretching exercises to build strength
2. Bed exercises for legs, arms and whole body
3. Bed mobility, which includes rolling and using muscles to sit up in bed
4. Sitting on the edge of a bed, which helps regain core strength
5. Seated balance exercises for legs and arms
6. Long sitting: Sitting at an angle of at least 30 degrees or higher, whatever the elder can tolerate
7. Working with weights where appropriate:  It’s going to have a different impact on an elder when they’re sitting up versus lying down. (Working against gravity as much as possible is important)

You can’t take someone who’s been lying in bed for ten days and say, “Okay, get up and walk.” An occupational therapist will help an elder through the above processes to make sure that they’re going to be safe when they do attempt to stand.

Every individual is different; it’s an occupational therapist’s responsibility to meet the person where they are and understand what their barriers, challenges, goals and needs are in that moment. 

How Occupational Therapists Modify Homes to be Safer

Home assessments are fundamental to personalized care, and especially when recovering after a hospital discharge. An occupational therapist will visit an elder’s home to identify potential problems, offer advice on things that should be modified, or how to address safety issues via specialized equipment.

They make sure the home is set up to ‘work’ for that person, and to help them be as safe and independent as possible. For example, they’ll look for things like tripping hazards, they’ll look at the bathroom design to see if an elevated toilet seat is required, if grab bars are needed, how accessible things are in the kitchen, and so forth.

By seeing in-person what an elder needs to be able to do, an occupational therapist can help to redesign the home to make sure that it’s a good fit for the elder.

What to do When an Elder Can’t Walk Anymore?

If an elder can no longer walk, they will likely use a wheelchair. This seems obvious, but not all wheelchairs are the same! An occupational therapist can assess the specific features that the elder will need. 

For example, for an elder who’s sitting in a wheelchair for long periods, it’s important that they use gel or pressure-relief (ROHO) cushions, and not foam cushions. ROHO cushions contour to a patient’s body and prevent pressure ulcers, so they’re great for an elder who has less ability to shift their position and redistribute their own weight.

Furthermore, it’s important to prevent pressure ulcers by changing position every two hours. Whether someone’s in a bed or chair, they can get pressure ulcers!

Are Transport Chairs Safe?

Transport chairs are only used for quickly moving people from one place to another.  They’re not recommended for long-term use. Here’s why:

1. They don’t have the same functions as a normal wheelchair
2. The wheels are much smaller and the person is not able to move
3. People with chronic back pain put a lot of pressure on their back when using their feet to push themselves around (due to the forward and backward motion of their feet)
4. The brakes are not as accessible, so some people might not be able to reach the brakes, which in itself is a safety issue
5. The armrests can’t be removed
6. They typically don’t have as much support as a regular wheelchair, which can cause a lot of problems when used for longer periods

Whenever possible, use a regular wheelchair for day-to-day activities!

Post-Stroke Care From an Occupational Therapist

Example: What would an occupational therapist do in this case?

You’ve got a gentleman who’s 75 years old. He’s had a stroke; he now as weakness on his right side, and is right-hand dominant. Caregivers are working on improving his walking, but there are issues with feeding. What sorts of adaptations can you make for someone with weakness in their dominant hand?

The Solution:

Post-stroke, an occupational therapist will typically focus on the upper body. It’s important to get the elder’s arms, fingers, and hands working again so he can do everyday things again like feeding himself. 

The therapist will likely start with passive movement, if the patient is able, then move on to physically assisting them achieve a fuller range of motion. 

Strength conditioning would come next, and when appropriate, weight can be added. Facilitation or inhibition techniques can be used depending on the patient’s muscle tone. It’s also important to consider sensation in the extremities, and the overall quality of movement. Repetition is key!

The patient may need to use some adaptive equipment. For example, there’s a device called a “universal cuff” that’s great for engaging in daily activities when the patient doesn’t have good grip strength. It’s worn on the hand, and can be used with, say, a spoon, fork or toothbrush. The elder can even use weighted utensils if he has issues with ataxia or tremors.

While every case is different, there are a lot of ways an occupational therapist can intervene and get their patient back to doing normal daily activities — and back to living a fulfilling life.

To speed up post-stoke recovery, an occupational therapist will often restrict the use of the other hand — because it’s easy for the patient to get frustrated and to want to use the hand that’s working correctly to jump in and reposition something slightly, or to help that hand that’s not functioning properly. It’s easier to “force” progress by eliminating use of the other hand. 

In certain cases, it may be better to use both hands. For example, the patient might need to have one hand stabilizing an object while the other is completing the actual movement. (To, say, open a jar or pick something up) 

Using a Smart Device to Deal with Poor Compliance in Taking Medication

From Dr Liz:

“One of my most interesting cases is someone that I’m working with currently. 

This person ended up having a fall in their bathroom, went to the hospital, found out that they had a hairline fracture, came back to our community, and went through the evaluation process. 

After my first couple of treatments with this person, I started to realize that they weren’t taking their medications. There was zero adherence to all the medication that was sent home from the skilled nursing facility. So I started to home in on that, and look into the cognitive aspect. We had many iterations of trying different types of medication management — for example, using pillboxes. I had to put a lot of written instructions there for every step. But that still wasn’t working, and we still weren’t getting full compliance. So we ordered this smart device that’s been working phenomenally. 

It’s connected to his cell phone, and I’m able to be connected to it; his partner is, too. Every day, I can see when he’s taking his medication. I get a notification if he misses a dose, and so does his partner. Since we started using this device, he’s had 100% compliance, and every day he says, I don’t know what I did without you, I don’t know what I did without this machine. Thank you so much. This has been such a burden on me for many years. 

I found medication labelled from 2013 that was still in the bag from the pharmacy, and for many years in between, indicating that he hasn’t been managing medication. Helping him work through that was a great experience for me, and the highlight is seeing how big of an impact this has made on his life and health.

Start working toward your best life and appreciate your occupational therapist — because often they’re the ones who do dig a little deeper, and see what’s really working and what isn’t.”