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a Healthcare Plan Developed for

MR James RYAN

Health Fusion 2019 - Meet the Team!

Jane - Speech and Language Therapy

Megan - Occupational Therapy

Lauren - Dietetics

Dominyka - Psychology

overview

Getting to know James

WHO?

James in the context of CAMM-UL & ICF framework

Addressing primary Goals of James, ROSEMARY and MDT

TREATMENT PLAN

6-month review & looking ahead

CAMM-ul

CAMMUL: Case Management model, university of limerick

WHO?

Understanding social supports and barriers, diagnosis, prognosis, current functioning levels, Assessment

WHAT?

SMART goals for intervention, client-centred practice and prioritisation

HOW?

Treatment approaches (MDT, key workers, etc.)

EFFECT?

Measuring change & establishing outcome expectations

WHERE NEXT?

Review and reassess goals, plan for future & long-term management

Franklin, S, Kearns, A, Kearns, T, ,McCurtin, A, Murphy, C.A & Wright, A (2015)

Health condition

Parkinson's disease (PD)

  • a degenerative, progressive disorder that affects nerve cells in deep parts of the brain called the basal ganglia and the substantia nigra. Nerve cells in the substantia nigra produce the neurotransmitter dopamine and are responsible for relaying messages that plan and control body movement. (Mayfield Brain and Spine Clinic, 2018)

ICF

participation (RESTRICTIONS)

  • Involvement in groups (historical society and drama group) has ceased
  • Does not leave house or connect with social network, impacts on wife
  • Disengaged with healthcare system
  • symptoms worst in morning

INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY & HEALTH

ACTIVITY (LIMITATIONS)

  • fatigue
  • Drives and manages ADLs but not leaving home
  • Difficulty turning in bed
  • Can take an hour to eat meals
  • Unsure if taking meds

BODY STRUCTURES AND FUNCTIONS

  • Rigidity and bradykinesia
  • Resting tremor on right upper limb
  • Stooped posture
  • Blank facial expression
  • Bruised right eye
  • Poor speech articulation and mild dysarthria
  • Short steps, normal gait
  • Normal BMI
  • Low blood pressure

ICF

personal factors

  • 67 year old man
  • Diagnosed in 2013 (6th year with PD)
  • Lives with wife, main caregiver
  • Retired school teacher
  • does not mention children/other family
  • attitude toward healthcare system

environmental factors

  • Lives in 2-story “old” farmhouse
  • Lives in rural area and not currently accessing any external supports, medical or otherwise
  • Support of wife only; isolated from all other possible supports

(World Health Organization, 2013)

RATIONALE FOR GOALS

OT and psychologist to meet James first, get informed consent, and build rapport with James and Rosemary; talk through THEIR goals with them to ensure client-centered care

Activities and

Participation

Body Structure and Functions

Environmental Factors

+

WHAT? HOW?

Ethical Practice

Personal Factors

YOU note mild-moderate dysarthria, low speech volume and poor speech articulation

by the end of the episode of care, james will successfully implement the fundamentals of the lsvt LOUD programme in social situations measured at the level of his activity and participation (miller and britton, 2011)

goal 1

"I know Rosemary wants us to go out more, and I'd like to, but my voice is just too quiet. I'm afraid that no one will be able to hear me me .. I used to be a loud enough when I was out you know! "

INFORMING GOAL: assessment

Dysarthria

Dysphagia

ASSESSMENT

fRENCHAY DYSARTHRIA ASSESSMENT (FDA-2)- SEVERITY + IMPACT ON QOL

high incidence of changes in swallow IN PD

(LEOPOLD AND KAGEL, 1996)

EVALUATION OF SPONTANEOUS SPEECH

OROFACIAL EXAMINATION ,

SENSORY ASSESSMENT REFLEXES,

DRY SWALLOW, SWALLOW TRIALS

REFERRAL FOR VIDEOfluoroscopY

ASSESSING COMMON SPEECH FEATURES: BREATHING, PHONATION, RESONANCE , PROSODY

Lee-silverman voice treatment loud programme

Intensive, High Effort Therapy

how?

(Dysarthria

+

dysphagia)

Dosage: 4 consecutive days a week for 4 weeks

Rosemary as co-therapist (Kalf et al.)

Training as conversational partner

Motivating for James

"Think loud"

Improvements in motor speech + swallowing (El Sharkawi et al. 2002)

"It can take him up to an hour to eat a meal because of the shake, I'd love if we could go out for dinner now and again to spare me cooking but he's too self-conscious"

By the end of the episode of care, james will...

goal 2

consume a nutritious, high energy and protein diet to prevent weight loss through TMD which will be measured by monitoring weight over the next 3 months

how?

nutrition requirements

BMI is within healthy weight range but must be monitored weight to prevent weight loss (cachexia and sarcopenia) and risk of malnutrition. James may be weak or have postprandial hypo-tension.

Energy requirements:

  • Weight: 54kg
  • Height: 1.5m
  • BMI: 24 (healthy)
  • Age: 67 yrs

High energy/protein diet

Henry Oxford Equation to calculate:

  • 2,000 Kcal/day
  • 1.6L fluids/day
  • 67.5g protein/day

Exercise - daily walk: benefit from socialisation and fresh air

Nutrition education

  • Educate James and his wife on TMD and the best foods to consume
  • Food pyramid
  • Meal and medication timing

Food/nutrient delivery

  • Food first via food fortification
  • Prescribe Oral Nutritional Supplements (ONS)
  • Texture Modified Diet (TMD)

Co-ordination of care

Closely monitor TMD with SLT and community nurse

Nutrition care plan

DIet Plan

Take diet history

Assess nutritional status

Discuss with james the food he enjoys eating and devise a suitable diet plan together

Aim for a healthy diet:

  • 3-4 whole grains for fibre (heart and GI health),
  • 5-7 portions of fruit and vegetables everyday (antioxidants for brain and essential micronutrients),
  • 3-5 portions of dairy for bone health,
  • 2 portions of meat, fish, eggs, beans seeds and nuts
  • Reduce salt, refined sugar and trans fat intake,
  • Limit alcohol consumption
  • Caffeine has been shown to have some neuroprotective effects, limit intake to no more than 3-4 cups per day of tea/coffee
  • Vit D supplement

Sample foods for James following swallow assessment

"I wish I weren't so tired all the time - it makes it hard to want to do things."

by the end of the episode of care, james will have the knowledge and confidence to manage his routine, including activities of daily living and medication

goal 3

how?

YOU SUSPECT ERRATIC MEDICATION CONCORDANCE

  • INFORMED CONSENT FOR COGNITIVE BEHAVIOURAL THERAPY
  • Medication Adherence: explore feelings and keeping diary (Osterberg & Blaschke, 2005).
  • REFER TO pd NURSE SPECIALIST to carry out Unified parkinson's disease rating scale (UPDRS) & conduct psycho-education for james and rosemary --> inform & support CBT process
  • Pleasant Activity Scheduling CBT (Boynes, 2012)
  • Home as ‘environmental cue’ for his medication adherence and other tasks assigned to him.

There could be a number of reasons why James is having many symptoms despite being prescribed medication: medical adherence, taking medications on an empty stomach (causing nausea) which would result in medication not being absorbed, taking medication after a high protein meal or the medication is no longer effective (L-dopa effectiveness may decrease after prolonged use)

Prolonged use of Levodopa can result in nausea, vomiting and hypotension as well as James being prescribed anti-hypertensives.

It is likely he could come off the blood pressure medication and manage it with diet and lifestyle changes, a decarboxylase inhibitor, can be combined with levodopa to minimise these side effects otherwise.

Timing of L-dopa medications around mealtimes to ensure that dietary protein does not interfere with the absorption of the L-dopa across the blood-brain barrier. It has been suggested that there should be a 40-minute delay between taking L-dopa and eating a meal.

L-dopa side effects

Dyskinesia

Nausea and vomiting

Heart failure & anemia

Anxiety, mania, depression

hypokalemia & hyponatremia

pheochromocytoma

Lupus-like syndrome

hIS SYMPTOMS of rigidity and bradykinesia ARE MORE PRONOUNCED IN THE morning and leave him feeling very fatigued

  • conduct FATIGUE IMPACT SCALE assessment, copm to assess and reassess aDLs (toileting, transfers, self-care)
  • STRATEGIES TO BUILD UP MORNING ROUTINE AND MANAGE FATIGUE
  • EVALUATE TIMES OF DAY HE FEELS BEST with CBT AND INTRODUCE activities then (such as intrinsic/extrinsic cues)
  • HOME ASSESSMENT TO ENSURE OPTIMAL SAFETY AND COMFORT, BRING IN ASSISTIVE TECHNOLOGY AS NEEDED (i.e. bed lever to enable independent turning in bed)

"James is finding it hard to leave the house and face old friends, and I don't feel right leaving him so we haven't been going out much."

goal 4

by the end of the episode of care, james will be actively moving around and/or outside house for 30 minutes a day with rosemary

how?

ROSEMARY TRIES TO ENCOURAGE JAMES TO RECONNECT WITH HIS SOCIAL CIRCLE, BUT HE IS RELUCTANT

caregiver self-assessment questionnaire

refer to physiotherapist for falls assessment and prevention techniques

develop carer support and management plan with Rosemary and James

REFER to physiotherapist for amplitude exercise program (LSVT-BIG)

link rosemary and james with parkinson's association for peer support network

Gradually build confidence & motivation to engage in local community again

Impact and Outcomes

1

Increased vocal loudness, improved articulation, vocal quality and intonation (Fox et al. 2011)

Post 1mth LSVT oral transit time, pharyngeal transit time, and vallecular residue decreased (Sharwaki et al. 2002)

EFFECT?

He will maintain his weight status

2

3

where next?

Ability to manage own routine with less fatigue, take meds, complete tasks of daily living safely, and become more motivated to complete activities

4

James feels comfortable moving around, and him and Rosemary start getting out and about again, building up support & social networks

FUTURE RECOMMENDATIONS

for 6 month review

Goal 1

Goal 2

Goal 3

Goal 4

Re-administer Frenchay Dysarthria Assessment to ensure improvement has generalised

where

next?

Thick and easy may need to be ordered for dysphagia

Weighted cutlery for tremor

Monitor weight

Gradually build on exercise program & expose couple to increased opportunities for peer support.

Continue to monitor ADL performance (driving, incontinence, transfers) and need for AT.

Perform COPM again to track areas of progress/setbacks.

Consider sleep & gauge for mental health problems.

THANK YOU!

references

REFERENCES

REFERENCES

BC Cancer Agency (2015). Easy to Chew, Easy to Swallow Food Ideas. Oncology Nutrition. [online] Vancouver: BC Cancer Agency. Available at: http://www.bccancer.bc.ca/nutrition-site/Documents/Patient%20Education/EasyToChewEasyToSwallowFoodIdeas%20-%202015.pdf [Accessed 24 Feb. 2019].

Drugs.com. (2019). Levodopa Side Effects in Detail - Drugs.com. [online] Available at: https://www.drugs.com/sfx/levodopa-side-effects.html [Accessed 9 Feb. 2019].

Duffy, Joseph R. (2013) Motor speech disorders : substrates, differential diagnosis, and management . Third edition. St. Louis, Mo: Elsevier Mosby.

Fox, C et al. (2012) LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease. Parkinsons Disease. [Online] 2012 (2012), 391946.

Indi.ie. (2019). Eating Well With Parkinson's Disease - INDI. [online] Available at: https://www.indi.ie/resources/fact-sheets/515-eating-well-with-parkinson-s-disease.html [Accessed 12 Feb. 2019].

Parkinsons.org.uk. (2019). Homepage Parkinson's UK. [online] Available at: https://www.parkinsons.org.uk [Accessed 14 Feb. 2019].

Seidl, S., Santiago, J., Bilyk, H. and Potashkin, J. (2014). The emerging role of nutrition in Parkinson's disease. Frontiers in Aging Neuroscience, [online] 6. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3945400/ [Accessed 12 Feb. 2019].

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