Renee Kinder

The new admission to your facility with underlying dementia who is a poor historian and has no family appears to not understand directions during ADLs and cannot demonstrate orientation to place.

The patient who is status post repeated strokes, times three, appears unresponsive to the voice of caregivers, however wakes with ease when he hears the voice of his wife at bedside. They have been married for 68 years.

The individual who was admitted following a hip replacement, however also presents with severe expressive aphasia and appears unable to speak beyond a word level. You have a sense that something has occurred beyond or during the surgery, and her family lives 800 miles away.

Then you have the clinical educator, me, who arrives in Texas to encounter all of these unique cases and is “upgraded” from her standard, and safe I may add, full-size car rental to a drop top convertible.

Terrified is an understatement. I am much more comfortable in a minivan, loaded down with car seats, crumbs and “Berenstain Bears” playing in the background.

Today, however, there are no standard cars available, the line of angry customers is growing, and the agent tells me with a wink, “I’ve got a car for you.”

The work façade had him fooled. I am not as adventurous as I appeared.

My first task when I arrive at the skilled nursing facility was to meet with the administrator and owner, establish my goals and objectives for the visit and seek feedback.

He was engaged and agreeable but also wanted to make me aware of the upcoming payment reform coming to the industry. As I was leaving his office, he handed me an article that he suggested I read on my flight home. I smiled as I glanced through the article. An article I had written.

Once again, I was not as I appeared.

We see a similar phenomenon in rehab patients, often at initial presentation they are not as they appear.

Case One: Dementia appears to have stripped away my memory

As I enter his room with occupational therapy, he was receiving care from his nursing assistant. We had reviewed the medical record from the hospital stay, “refuses care,” “combative,” “dementia.”

The therapist begins her initial evaluation by making an introduction, “Good afternoon, I am your occupational therapist. Where are you from?”

No response.

The OT shifts her approach.

“Which town are you from in Texas?”

No response.

She takes it down one more level and provides a field choice.

Are you from Denton or Dallas?

“Denton.” Success.

“Great. I am here to see how you move around within your bed and to see if we can complete some out of bed tasks. Is that OK?”

No response.

The OT shifts her approach.

“Can we see how you move?”

No response.

She takes it down one more level and closes the question end.

“Can you move in bed? Yes or No?”

Response, “Yes.” Success.

I then had the pleasure of observing this skilled, caring OT adjust and alter her approach while completing an evaluation, meeting the patient where he was in his disease process, to develop an appropriate ability-based plan of care. 

Case Two: My stroke is new and chronic

The 2016 guidelines for best practice in treating stroke as recommended by the American Heart Association and American Stroke Association in the Journal of Stroke state that stroke should be viewed as a chronic condition with greater than 30% of stroke survivors reporting persistent participation restrictions up to four years after onset.

We saw him at bedside, his loving, dedicated, sweet wife present as she had been after the first stroke and the most recent two he suffered in the last 30 days.

Caregivers were challenged with his limited responsiveness. His presentation was at the lowest level of function requiring sensory stimulation for engagement.

Following a stroke, tactile deficits can be the most common form of sensory deficit and can impact 40% to 80% of individuals, resulting in reduced awareness of stimulation including tactile, temperature, pressure, vibration and proprioception.

Reduced sensory awareness has also been linked to activity limitations and participation restrictions after stroke but can improved with appropriate therapeutic intervention, including those based on multimodal interventions.

In this patient’s case, increased sensory awareness was gained with tactile stimulation to the oral cavity for swallow. Also, the auditory stimulation of his wife’s voice allowed for increased awareness of his environment.

Case Three: I have a new hip and I can’t find my words

She wanted everyone “OUT” of her room, she had a new hip replacement and was at risk for falls. Unable to communicate, she was tired and frustrated. Or so it appeared.

Upon first entering her room with physical therapy, I was overwhelmed by the television volume in the background. The decibel level of her daily news added to the confusion in her voice.

After adjusting the volume, we started asking questions to gain insight into her prior level of function.

“Can you tell me why you are here?”

She rolls her eyes and points to her leg with a jargon laced response.

We change our approach.

“Did you break your hip?”

“Yes, I broke my hip, broke my hip, broke my hip.”

Success, with perseveration, but success nonetheless.

“How did you enjoy spending your time prior to breaking your hip?”

“Nothing,” her tone sharp.

We adjust approach, changed question formatting to yes/no responses, implement field choice for question and ensured she understand directions before requesting physical movement.

Within five minutes of physical therapy engaging the patient who appeared unable to communicate and appeared to refuse interaction with caregivers, this individual was able complete functional bed mobility tasks and communicate that she enjoyed reading mystery novels in her free time. Successful therapy was achieved by engaging her at her level, based on her abilities.

As I pulled back into the rental car return three days later, my appearance said it all. Smiling, relieved to return what most would have considered a dream to drive, and grateful for the opportunity to spend a couple of days with a team of therapists who understood that their patients are not always as they appear.

Renee Kinder, MS, CCC-SLP, RAC-CT currently serves as Director of Clinical Education for Encore Rehabilitation and acts as Gerontology Professional Development Manager for the American Speech Language Hearing Association (ASHA).