Maximizing Therapist Effectiveness with Geriatric Hand Patients

Cynthia Cooper, MFA, MA, OTR, CHT

Clinical Instructor, University of Southern California, Department of Occupational Therapy, Los Angeles, California

Last year I treated a 66-year-old right-hand­dominant woman with a diagnosis of meta­

carpophalangeal (MP) arthroplasties of the right in­dex through little fingers secondary to rheumatoid arthritis. She came to therapy one day, having some­how applied her dynamic MP flexion loops to accom­plish MP extension instead of flexion, convoluting the strap attachment and practically turning the soft components inside out. She could not demonstrate "simple" isolated exercises accurately and could not remember to refer to her written instructions for di­rection or help.

Surprisingly frequently I see volar digital gutter splints incorrectly applied dorsally instead of volarly by older patients. Also, I have been struck by un­expected difficulty with placement and strap closure of relatively simple, hand-based splints . Conversely, I have also treated some quite elderly patients who demonstrated excellent understanding and follow­through with more complicated splint use and home exercises.

STATISTICS ON AGING

People who are 65 years of age or older comprise 12% of the population of the United States. 1 The oldest-old, defined as those at least 85 years of age,

Adapted from a paper presented at the 14th Annual Meeting of the American Society of Hand Therapists, Orlando, Florida, Sep­tember 26-29, 1991.

Correspondence and reprint requests to Cynthia Cooper, MFA, MA, OTR, CHT, University of Southern California, Department of Occupational Therapy, 2250 Alcazar Street, CSA 203, Los An­geles, CA 90033.

ABSTRACT: The "graying of America" is resulting in higher pro­portions of older persons utilizing the health care system. Current trends indicate that the geriatric population represents a growing portion of the hand therapy patient population . Appreciating the unique needs of the geriatric hand patient and developing an appropriate treatment program require special interventions that may seem unappealing due to the likelihood of prolonged initial treatment time. However, such steps can strongly enhance ther­apist effectiveness, patient compliance, and ultimate outcome. The purposes of this paper are: (1) to address frustrations that may be encountered in the treatment of some elderly hand pa­tients; (2) to introduce the reader to the phenomenon of age bias; (3) to present a well-accepted and effective assessment tool of memory, orientation, and ability to follow commands as these competencies pertain to hand therapy; (4) to address concepts in the gerontology literature that can be applied clinically as treat­ment gUidelines to boost treatment effectiveness; and, finally, (5) to suggest communication techniques to use with the elderly hand patient. Maximizing therapist effectiveness with geriatric hand patients will serve to reinforce the dignity and value of this unique population.

reflect the most rapidly growing segment of the U.S. population. 2 Chronic degenerative diseases have sur­passed infectious diseases as the major health threat in our nation. 3 Thus, the geriatric population repre­sents a growing portion of the hand therapy patient population. Acknowledging the unique needs of this group and individualizing an effective program re­quire special considerations that may prolong initial treatent time but can strongly enhance therapist ef­fectiveness, patient compliance, and ultimate clinical outcome.

PURPOSE

The purposes of this paper are: (1) to address frustrations that may be encountered in the treatment of some elderly hand patients; (2) to introduce the reader to the phenomenon of age bias; (3) to present a well-accepted and effective assessment tool of memory, orientation, and ability to follow commands as these competencies pertain to hand therapy; (4) to address concepts in the gerontology literature that can be applied clinically as treatment guidelines to boost treatment effectiveness; and, finally, (5) to sug­gest communication techniques to use with the el­derly hand patient. Maximizing therapist effective­ness with geriatric hand patients will serve to reinforce the dignity and value of this unique population.

FRUSTRATIONS

The gerontology literature is rich with articles and studies documenting age-related decline in the speed of cognitive processing.4-10 Cognitive symp-

July-September 1993 205

toms may be the first signs of mental deterioratio~, leading to progressive manifestations such as a~xI­ety, agitation, and behavioral outb.urstsY Hean~g loss can result in significant emotIonal and socIal problems and communication barriers.12 All sensory functions slow with age. 13 In addition, wound heal­ing may be slower: studies have shown that ag~d mice demonstrated slower wound closure than dId young mice. 14

Behavior in general becomes slower with age,IS which can be challenging to a busy, overbooked ther­apist. Older people may have diffi~ulty ignoring ~r­relevant stimuli such as ambient nOIse, mtertherapist dialogue and other therapist interruptions. 16 Some older ad~lts have been found to use less effective problem-solving strategies, seem to lack recognition of the value of problem-solving strategies, and ask questions of lower effectiveness. I7

Many of our older han? patients may ~e d~­pressed. According to the hterature, depressIOn IS the most frequent functional disorder among the el-derly.18 .

Physical performance generally decreases WIth age. 19 Skills that are used infrequently are most af­fected by age.20 Elderly patients may occasionally seem to be "crotchety" (i.e., painful or lonely) and "stub­born" and "noncompliant" (i.e., uncomfortable re­linquishing their independence).

Age bias against elderly people may be reflec~ed in our caregiving. Societal biases toward, negatIve perceptions about, and stereotyp~s of eld~rly people have contributed to age segregatIon. SOCIal dIstance has fostered the devaluing of older people21 and underscores the need for geriatric training among health professionals. 22

MINI-MENTAL STATE EXAMINATION

The Mini-Mental State Examination (MMS)23 (Appendix A) is a simple, reliable, and valid assess­ment tool that can be administered by a lay person. It requires 5 to 10 minutes to administer. It focuses on cognitive aspects; it does not address mood. There are two sections to the MMS: (1) vocal response en­tailing orientation, memory, and ~ttention; and (2) naming, following verbal and wntten comm~nds, spontaneously writing a sentence, and ~opymg a complex polygon. The MMS has bee~ stu.dIed ex~en­sively, and there is copious informatIon m the hter­ature substantiating its use. 1,11,24-27

According to its authors, Folstein et al.,23 the MMS "makes more objective what is commonly a vague and subjective impression of cognitive disa­bility" (p. 195). Low performance on the MMS can signal the need for social support in general. I suggest that performance on the MMS .reveals a valuable in­dicator of possible obstacles WIth hand therapy fol­low-through and compliance, identifi~~ learning strengths versus limitations, and ~hus faCIhtates gen­eration of realistic and appropnate hand therapy treatment goals. It may also be a useful preoperative screening tool.

206 JOURNAL OF HAND THERAPY

Candidates

Ideally, the MMS is a good screening tool for any patient who appears to have memory problems or who demonstrates extra "creativity" and/or bi­zarreness with interpretation of instructions or splint application. The MMS may reveal meaningful find­ings with any patient who is not complying, partic­ularly the patient who seems to be trying but cannot demonstrate accurately.

Maximum score on the MMS is 30. A score of less than 24 indicates some cognitive impairment. Hand therapy with this type of patient may warrant reinforcement with support or supervision.

A score of less than 20 indicates difficulty com­prehending.28 If memory items are involve~, the pa­tient is likely to be unable to remember hIS or her exercises or even to look at his or her written instruc­tions. This patient probably requires close supervi­sion for all aspects of therapy and could be ~ v~ry poor candidate for elective ~urg~ry necessItah~g postoperative therapy. If a patIent IS elderly and dI~­oriented and relies on an elderly spouse for help, It may be useful to administer the MM~ to the spo.use (see first section of MMS in AppendIX A for onen­tation items).

The MMS screens one's ability to follow visual, auditory, and motor commands. These valuable find­ings can be translated into appropriately selected pa­tient instructions designed to tap the patient's areas of demonstrated strengths. For example, a patient who responds better to a visual command may do well with written home instructions, whereas a pa­tient who responds better to an auditory command may require an emphasis on verbal instruction and reinforcement. Difficulty with a motor command may suggest deficits that could affect significantly the abil­ity to doff and don splints or perform isolated ex­ercises accurately.

If a patient's score is 25 or above and he or she can recall a complex item such as a new exercise after 5 minutes have elapsed, this is a good indicator of ability to follow through with home instructions. 28

It is my impression that the MMS is an especially helpful clinical tool for identifying patients who are disoriented and patients with profound memory loss. In addition, it has been valuable in guiding the qual­itative emphasis of a program (Le., justifying an em­phasis on instructions that are written versus verbal versus demonstrated).

TREATMENT GUIDELINES

The folowing guidelines have been synthesized from the gerontology literature:

1. Allow extra time to treat elderly patients to ac­commodate the possibility of slower cognitive pro-cessing and slower physical performance. .

2. Eliminate and/or reduce interferences and ambIent stimuli.

3. If the MMS score reflects certain strengths, use

them. Written instructions, phonemic informa­tion, and/or physical practice with simultaneous verbalizing may enhance learning. 29

4. Keep dexterity demands minimal if possible. 5. Simplify straps on splints; permanently secure one

errd of each strap; color-code strap ends. 6. Simplify overall numbers of devices or splints. 7. Acknowledge the patient's physical presence.

Therapeutic touch of a disoriented patient may help him or her focus on the task. Interestingly, it is hypothesized that tactile receptivity may be retained when other senses have deteriorated. 30

TALKING TO THE ELDERLY

Finally, here are some suggestions to improve communicaton effectiveness with elderly people31 :

1. Do not rush them. If you do, they may slow down. 2. Remember that many elderly individuals can still

learn, grow, and develop. 3. Do not shout. This just distorts speech perception

and may also embarrass the patient. Lower your voice. Face the patient directly.

4. Use visual aids. 5. Focus on activities of daily living (ADL) if tradi­

tional learning and memory problems exist. 6. Express interest. 7. Remember that many elderly persons perceive

themselves as much younger than their biological ages.

8. Acknowledge the value of the individual. 9. Be patient, or give the patient to another caregiver.

CONCLUSION

A hand therapist who may be well-versed in the treatment guidelines for the tissues involved may be stymied by the unique obstacles associated with some of our older hand patients. We have probably all felt the frustration of our efforts, being minimized by seemingly vague or strange deviations in follow­through or questionable recall or comprehension. Sensitizing oneself to geriatric issues and using the MMS may enable the therapist treating a geriatric hand patient to: (1) improve his or her objective ger­iatric assessment effectiveness; (2) minimize the de­mands placed on a patient's cognitive or perceptual limitations; (3) identify, appreciate, and utilize ap­propriate patient cognitive or perceptual strengths; and thus (4) reinforce the dignity and value of the geriatric hand patient. Maximizing therapist effec­tiveness will facilitate appropriate and realistic goal setting, eliminate unproductive or unnecessary treat­ments, yield more successful clinical outcomes and more enriching interaction between patient and ther­apist, and result in an improved sense of competence for clinician and patient alike.

Acknowledgment

The author thanks Malcolm B. Dick, PhD, for his generosity with time and thoughts.

REFERENCES

1. Brock CD, Simpson WM: Dementia, depression, or grief? The differential diagnosis. Geriatrics 45(10):37-43, 1990.

2. Manton KG, Blazer DG, Woodbury MA: Suicide in middle age and later life: Sex and race specific life table and cohort analyses. 1 Gerontol 42:219-227, 1987.

3. Sharps MJ, Gollin ES: Speed and accuracy of mental image rotation in young and elderly adults. 1 Gerontol 42:342-344, 1987.

4. Rook KS: Encouraging preventive behavior for distant and proximal health threats: Effects of vivid versus abstract infor­mation. 1 Gerontol 41:526-534, 1986.

5. Puglisi IT: Age-related slowing in memory search for three­dimensional objects. J Gerontol 41:72-78, 1986.

6. Rabinowitz IC: Priming in episodic memory. 1 Gerontol 41:204-213, 1986.

7. Hess TM, Slaughter 51: Aging effects on prototype abstraction and concept identification. 1 Gerontol 41:214-221, 1986.

8. Rice EG, Meyer BIF: Prose recall: Effects of aging, verbal abil­ity, and reading behavior. J Gerontol 41:469-480, 1986.

9. Hertzog C, Raskind CL, Cannon CJ: Age-related slowing in semantic information processing speed: An individual differ­ences analysis. J Gerontol 41:500-502, 1986.

10. Ager CL: Cognitive developmental changes. In Davis LJ, Kirk­land M (eds): The Role of Occupational Therapy with the Elderly. Rockville, Maryland, AOTA, 1988, pp. 69-78.

11. Deimling GT, Bass OM: Symptoms of mental impairment among elderly adults and their effects on family caregivers. 1 Gerontol 41:778-784, 1986.

12. Mulrow CD, Aguilar C, Endicott IE, et al: Association between hearing impairment and the quality of life of elderly individ­uals. 1 Am Geriatr Soc 38:45-50, 1990.

13. Levy LL: Sensory change and compensation. In Davis LI, Kirk­land M (eds): The Role of Occupational Therapy with the Elderly. Rockville, Maryland, AOTA, 1988, pp. 49-66.

14. Cohen BJ, Danon 0, Roth GS: Wound repair in mice as influ­enced by age and antimacrophase serum. J Gerontol 42:295-301, 1987.

15. Falduto LL, Baron A: Age-related effects of practice and task complexity on card sorting. 1 Gerontol 41:659-661, 1986.

16. Erber IT: Age-related effects of spatial contiguity and inter­ference on coding performance. J Gerontol 41:641-644, 1986.

17. Hartley AA, Anderson IW: Instruction, induction, generation, and evaluation of strategies for solving search problems. J Gerontol 41:650-658, 1986.

18. Gatz M, Pederson NL, Harris J: Measurement characteristics of the mental health scale from the OARS. J Gerontol 42:332-335, 1987.

19. Rikli R, Busch S: Motor performance of women as a function of age and physical activity level. J GerontoI41:645-649, 1986.

20. Menks F: Anatomical and physiological changes in late adult­hood. In Davis LJ, Kirkland M (eds): The Role of Occupational Therapy with the Elderly. Rockville, Maryland, AOTA, 1988, pp.41-48.

21. Luszcz MA, Fitzgerald KM: Understanding cohort differences in cross-generational, self, and peer perceptions. 1 Gerontol 41:234-240, 1986.

22. Yeo G, Ingram L, Skurnick J, et al: Effects of a geriatriC clinic on functional health and well-being of elders. J Gerontol 42:252-258, 1987.

23. Folstein MF, Folstein SE, McHugh PR: "Mini-Mental State": A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189-198, 1975.

24. Miller OK, Morley JE, Rubenstein LZ, et al: Formal geriatric assessment instruments and the care of older general medical outpatients. J Am Geriatr Soc 38:645-651, 1990.

25. Cooper JK, Mungas 0, Weiler PG: Relation of cognitive status and abnormal behaviors in Alzheimer's disease. JAm Geriatr Soc 38:867-870, 1990.

26. Heeren TJ, Lagaay AM, v Beek WCA, et al: Reference values for the Mini-Mental State Examination (MMSE) in octo- and nonagenarians. J Am Geriatr Soc 38:1093-1096, 1990.

27. Kaye K, Grigsby J, Robbins LI, et a1: Prediction of independent functioning and behavior problems in geriatric patients. J Am Geriatr Soc 38:1304-1310, 1990.

July-September 1993 207

28. Dick MB: Personal communication. Alzheimer's Disease Treat­ment Center, University of California-Irvine, 1991.

29. Rissenberg M, Glanzer M: Picture superiority in free recall: The effects of normal aging and primary degenerative de­mentia. J Gerontol 41:64-71, 1986.

30. Eaton M, Mitchell-Bonair IL, Friedmann E: The effect of touch on nutritional intake of chronic organic brain syndrome pa­tients. J Gerontol 41:611-616, 1986.

31. Anderson EG: How not to talk with elderly patients. Geriatrics 45(1):84-85, 1990.

ApPENDIX A

Mini-Mental State Examination23*

"Now I would like to ask you some questions to check your memory and concentration. Some of them may be easy and some of them may be hard."

1. What is the year?

2. What is the season of the year?

3. What is the date?

4. What is, the day of the week?

5. What is the month?

6. Can you tell me where we are right now? (For instance, what state are we in?)

7. What county are we in?

8. What city/town are we in?

9. What floor of the building are we on?

___ 10. What is this address?

11 . I am going to name three objects. After I have said them, I want you to repeat them. Remem­ber what they are because I am going to ask you to name them again in a few minutes. Apple

Table

Penny

Please repeat the names for me. (Score first try . Repeat objects for three trials only.)

12. Now I am going to give you a word and ask you to spell it forwards and backwards. The word is WORLD. First, can you spell it for­wards? Now spell it backwards. (Repeat if nec­essary, and help subject spell word forwards, if necessary.) (Score number of letters given in correct order.)

'Reprinted from J Psychiatr Res, Vol 12, Folstein MF, Folstein SE, McHugh PR, "Mini-Mental State" : A practical method for grading the cognitive state of patients for the clinician, pp. 196-198, © 1975, with kind permission from Pergamon Press Ltd, Headington Hill Hall, Oxford OX3 OBW, UK.

208 JOURNAL OF HAND THERAPY

What were the three objects I asked you to remember?

__ 13. Apple

___ 14. Table

___ 15. Penny

___ 16. (Show wrist watch.) What is this called?

___ 17. (Show pencil.) What is this called?

__ 18.

__ 19.

20.

I would like you to repeat a phrase after me: (The phrase is) 'NO IFS, ANDS, OR BUTS: Allow only one trial. Read the words on this page, then do what it says. (The paper reads) 'CLOSE YOUR EYES' (Fig. 1). Code correct if subject closes eyes. I'm going to give you a piece of paper. When I do, take the paper in your right hand, fold the paper in half with both hands, and put the paper down on your lap. (Read full statement, THEN hand over paper. Do not repeat instruc­tions or coach.) Right hand

Folds

In lap

___ 21. Write any complete sentence on that piece of paper for me.

___ 22. Here is a drawing. Please copy the drawing on the same paper (Fig. 2). (Score correct if the two five-sided figures intersect to form a four­sided figure and if all angles in the five-sided figure are preserved.)

D TOTAL SCORE IS THE SUM OF THE SCORES FOR ALL 22 QUESTIONS, EXCLUDING ANY ITEMS NOT ASSESSED.

CLOSE YOUR EYES FIGURE 1. The words shown to the patient in the Mini-Men­tal State Examination .23 The patient is asked to read the words, then do what it says.

FIGURE 2. The drawing used in the Mini-Mental State Ex­amination n The patient is asked to copy the drawing on the same paper.