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Dale 2 of 8

Occupational Therapy Case Study

  Setting

Home-based Therapy

  Patient Overview 

The patient is a  77-year-old male s/p diagnosis of progressive neurological condition with generalized mm weakness impacting balance, ambulation, attention, memory, mood, and participation in meaningful activities

Since July 2019, the patient’s caregiver has been concerned about memory deficits and mood changes affecting his ability to be independent or participate in general activity. 

These symptoms have resulted in decreased mobility, increased generalized pain and exacerbations, decreased ability to recall names and faces of familiar people, decreased ability to organize numbers, calculate, and problem solve during card games, shopping, and financial management and decreased desire to engage in social activity previously important to him. It has also increased caregiver burden.

 In November 2019, the patient and caregiver sought official neuropsychological testing…

In December 2019, Caregiver and patient attended…diagnosis where he was given dopezil. He had adverse symptoms (diarrhea and nausea) which led them to discontinue donepezil and prescribe a transdermal patch of Rivastgmine). This left them concerned they would experience side effects from future medications. 

 The patient and caregiver also attended a memory coordination meeting where they were educated on the diagnosis, directed to seek further information and follow-up with primary care. They continue to feel uncertain following basic overview. The patient will follow-up with ….  in 2-3 months. 

  Medical History

  • Generalized Dementia
  • Peripheral Neuropathy BLE
  • Pre-Diabetes
  • Lumbar Spinal Stenosis

  Body Structures

BUE ROM WFL

Exceptions: 

  • LUE FLEXION 90 degrees
  • LUE Abduction 90 degrees 
  • Functional AROM in scaption

Functional Movement Patterns (Strength)

 

  • B Shoulder Flexion 4 / 5
  • Shoulder Extension 4 / 5
  • B Elbow Flexion 4 / 5
  • B Elbow Extension 4 / 5
  • B HIP FLEXION 3 / 5
  • B KNEE EXTENSION 3 / 5

  Assessments

  • Dementia Rating Severity Scale (DSRS) : 10 – mild 
  • Five Time Sit to Stand 27.27 (Goal less than 12) 
  • SLUMS 17/30 
  • TUG 33 (Goal Less than 12) 
  • BERG 31/56

   Performance Deficits According to Occupational Domain

NumberPerformance DeficitsOccupational Domain Being Impacted

Restorative/

Habilitative

Potential

Skilled Maintenance Management

Required

2Increased memory deficits

IADLs – Financial Management, Safety maintenance, Shopping

Social Participation – Community PAR, Family PAR, Friendships

           x          x

  Treatment

Performance Deficits 

Increased memory deficits

Treatment

HEP  –  Brain HQ 

Dual Task : Unrelated Words with Agility Ladder (AL)

Short story reading/attention to detail questions with interference

 

Objective Measures 

How to gauge progress

  • Number of Unrelated Words
  • Number of orientation changes during one AL set
  • Number of sequenced steps to recall and execute during AL set
  • Tempo of Metronome (bpm) 

 

Explanation 

This treatment explanation is about the memory training components of this treatment. I will discuss the motor-based component separately. 

“Nerves that fire together wire together”. Attention is a key component of memory and memory 

Is divided into so many components! 

I brought two handwritten resources with me to the session. One resource that would allow me to read a segment of text and ask questions about it (I wrote out questions beforehand – now these attention to detail sheets are accessible in The Portal). The other resource was a list of Unrelated Words to list (also now accessible on The Portal). I also had an agility ladder I would bring with me wherever I went! An agility ladder is so good on multiple levels for occupational therapy! You can check out why on instagram where I break down the activity in one of the posts.

Agility ladder and buffalo occupational therapy

To set-up activity, I taped down the agility ladder in his hallway. I opened my metronome app and set it to 50bpm (this is my baseline for everyone); the beat allows the body to organize/coordinate movement more efficiently so that they can begin to also consolidate and retrieve information for the executive function portion of the task! 

 

Before having the patient perform a 6-step sequence pattern in the agility ladder to the metronome, I listed 4 unrelated words  – he walked down the arrow and back to start (20 ft) – and was required to give the words back to me or I read to him 8 words, 4 of them “filler words”, and he had to tell me if he had heard those words before. I actively graded this task based on performance during that set. When that was achievable for at least 2 sessions, I increased the words. We were able to increase to 10 words before discharge with varying step sequencing. 

 

 

The attention to detail activity was used in any activity we did. If we were doing exercise, I would read him a statement, continue with the exercise while having a timer for the correct amount of interference, and then ask the questions. The same was true with any activity except pelmanism. Out of 20 questions (5 statements) each visit, he was able to recall 14/20 questions exactly. He did improve in generalizability.

This was earlier in my practice. Since then, we have incorporated many more interventions for memory and dual tasking. 

Outcomes

According to the subjective feedback of patient and wife, the patient felt as though he was able to attend during conversations better, remember things quicker, and ultimately (along with other interventions described for “DALE”, he improved in his slums by 10 points over 18 weeks.

  References to begin your own critical analysis of this activity:

1.Castillo de Lima, V., et al., A Training Program Using an Agility Ladder for Community-Dwelling Older Adults. Journal of Visualized Experiments, 2020(157).

  1. Lemke, Nele C., et al., Transferability and Sustainability of Motor-Cognitive Dual-Task Training in Patients with Dementia: A Randomized Controlled Trial. Gerontology (Basel), 2019. 65(1): p. 68-83.
  2. Cheng, S.-T., Cognitive Reserve and the Prevention of Dementia: the Role of Physical and Cognitive Activities. Current Psychiatry Reports, 2016. 18(9): p. 85.
  3. Park, M.-O. and S.-H. Lee, Effects of cognitive-motor dual-task training combined with auditory motor synchronization training on cognitive functioning in individuals with chronic stroke: A pilot randomized controlled trial. Medicine (Baltimore), 2018. 97(22): p. e10910-e10910.
  4. Fritz, N.E., F.M. Cheek, and D.S. Nichols-Larsen, Motor-Cognitive Dual-Task Training in Persons With Neurologic Disorders: A Systematic Review. Journal of neurologic physical therapy, 2015. 39(3): p. 142-153.
  5. Reed-Jones, R.J., et al., Vision and agility training in community dwelling older adults: Incorporating visual training into programs for fall prevention. Gait & posture, 2011. 35(4): p. 585-589.
  6. Walker, T.B., et al., The Influence of Agility Training on Physiological and Cognitive Performance. Journal of strength and conditioning research, 2011. 25: p. S104-S105.
  7. Anderson, N.D., et al., Repetition Lag Training Eliminates Age-Related Recollection Deficits (and Gains Are Maintained After Three Months) but Does Not Transfer: Implications for the Fractionation of Recollection. Psychology and aging, 2018. 33(1): p. 93-108.