Dysphagia: Symptoms, diagnosis, and treatment - perfect grader

Dysphagia and Other Eating Incidences of swallowing, eating, and nutritional problems are

increasing as the elder population grows.

Chronic medical conditions that influence the ability to feed oneself include

arthritis, hypertension, heart disease, hearing impairment, mobility, diabetes, and visual impairments.
Lack of assistance for financial support, shopping, cooking, and so on

Malnutrition

Insufficie

Undernourishment

Taking in less nutrition than needed
May occur in elders who need assistance feeding

Dehydration

Taking in less or excreting more fluids than needed
May occur in elders who need assistance to drink or obtain fluids

Role of COTA in Dysphagia

1.Collect data to identify the strengths and weaknesses of elders in feeding and drinking.
2.Provide quality care to elders with swallowing problems.
3.Activities
4.Meal preparation, money management, shopping, oral-facial exercises, assistive devices

Normal Swallowing-Phases

Oral preparatory phase
Oral phase
Pharyngeal phase
Esophageal phase

Changes to Swallowing Structures

Occur naturally as we age
Compensations : Adaptations to swallow
Smaller bits, more chewing time, softer food
May need soft diets, liquid diets, and so on to prevent choking or aspiration

Dysphagia

Inability to swallow

Etiology of Dysphagia

Neurologic, structural, systemic

Aspiration pneumonia

Inhaling food or fluids into the lungs, resulting in a life-threatening form of pneumonia

Silent aspiration:

Aspirating food or fluids without coughing or choking and later developing pneumonia or other conditions

Intervention Strategies for Dysphagia

Establish a therapeutic relationship with the elder.
Focus attention on every aspect of the mealtime experience.
Position the elder, use his or her assistive devices, address his or her dietary concerns, and take necessary precautions.

Preparation Checklist for Dysphagia and Self-feeding Interventions

Collect information and review the chart.
Inform the elder of the treatment goals.
Create the right environment for eating.
Ensure proper fit of dentures, glasses, and so on.
Asses the patient for readiness to eat.
Position the elder safely.
Complete oral preparation exercises.
Check the food tray for the correct diet.

Intervention Strategies-Environmental concerns

Eating is part of socialization and quality of life.
The eating experience should be as aesthetically pleasing as possible.
Ensure good lighting with no distracting noises.
Allow plenty of time to eat.
Make sure the table is at the appropriate height.
Provide comfortable positioning.
Sit with pleasant table mates if the elder lives in a residential community or nursing home.

Positioning-Dysphagia

Safe positioning prevents food from entering the trachea (airway).
Proper positioning increases alertness, normalizes muscle tone, provides comfort, and helps with digestion.
Preferred position is in a dining chair rather than a wheelchair.
The elder should sit upright wit the feet on the floor and head and neck in alignment.
The extremities should be fully supported on the table or tray.
The hips and knees should be flexed 80 to 90 degrees.

Feeding in Bed-Dysphagia

Position as close to the headboard as possible.
Elevate the head of bed 45 degrees or more.
Flex the knees to prevent sliding down in bed.
Use pillows to position if needed.
Positioning devices may be used in chairs or beds.

Assistive Devices-Dysphagia

Straws
Built-up handles for silverware

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Universal cuff
Swivel spoon or long-handled spoon
Nonslip placemats or plates with suction cups
Spouted lids on cups
Rubber-coated spoons
Rocker knives for one-handed cutting

Direct Intervention-Dysphagia

Learning how to feed someone well takes practice.
Provide a large napkin (not called a “bib”) to catch stray food
Bring food to mouth slowly and watch for cues that the person is ready to take a mouthful of food.
Learn how much food the person will take in one mouthful.
Watch for chewing and swallowing; wait for the patient to swallow and clear the mouth before giving another spoonful.
Provides fluids to wash down the food bolus.
Coordinate eating and breathing.

Feeding Patients with Dementia

Provide finger foods if they can feed themselves.
Decrease environmental stimulation.
Reduce verbal communication to ease distractions.
Monitor so the patient with dementia does not eat “nonfood” items on the tray.

General Problems to Avoid-Dysphagia

Food too hot or too cold
Ill-fitting dentures
Not allowing enough time for chewing and swallowing
Not monitoring a patient at risk for aspiration while he or she is eating
Stopping the feeding before the elder has had time to consume the nutrition needed

Dietary Concerns-Dysphagia

Elders prefer softer, sweeter, easy-to-prepare foods.
Elders often drink fewer fluids.
Learn how liquid intake is measured in each health care facility so you will record the correct amounts of oral fluid intake.

National Dysphagia Diet Levels

Level I: Puree consistency diet (homogenous, very cohesive, pudding-like, requiring very little chewing ability)
Level 2: Mechanically Altered (cohesive, moist, semisolid foods, requiring some chewing)
Level 3: Dysphagia-Advanced (soft foods that require more chewing ability)
Regular (all foods allowed)

Fluid Consistencies-Dysphagia

Thin - regular consistency with no alterations
Nectar - slightly thicker than water
Honey - consistency of honey; trickles slowly off spoon
Spoon-thick - consistency of pudding

Precautions-Dysphagia

Observe the patient’s level of alertness, orientation, cognitive status, positioning, general endurance, and ability to self-feed.
Observe the presence of delayed swallowing, food pocketing (food retained between the gums and cheeks), choking, and a wet-sounding voice.
Be prepared to assist with choking using the American Heart Association methods for a choking person and CPR.

Signs and Symptoms of Aspiration

Coughing, gagging, or choking during mealtimes and immediately afterward
Rapid breathing, fatigue, or bubbly respirations during and immediately after meals
Intermittent elevated temperatures
Vomiting small amounts after meals and at night (spitting up)
Needing to take multiple swallows to clear food from the mouth
Drooling or having food fall out of the mouth
Eating or drinking rapidly and stuffing food in the mouth
Appearing fearful and reluctant to eat
Unexplained weight loss or being underweight

Ideas for Managing a Feeding Program

Get elders out of bed at mealtimes.
Ensure a pleasant dining environment without loud noise and distraction.
Set up each resident’s trays, dishes, and assistive devices so they are within easy reach.
The program should address all meals and include members of the interdisciplinary team.
Safety first!

Part I: Restraint Reduction-COTA role

Role of COTAs in restraint reduction
Assessment
Consultation
Environmental adaptations
Psychosocial approaches
Activity alternatives
Treatment

History of restraints

Physical restraints have been used since the 1700s in the United States to manage psychotic behavior.
Until the late 1980s, restraints were almost universally used in nursing homes.
Restraints continue to be used today in hospitals with a physician’s order.
Nursing homes have almost universally eliminated restraints.

Consequences of Using Restraints-Psychosocial

Depression, withdrawal, anxiety, fear, panic, and so on
Less social contact, humiliation, decreases in dignity and self-esteem

Consequences of Using Restraints-Physical

Hazards of immobility, incontinence, constipation
Loss of balance, falls, pressure ulcers
Pneumonia, infection, dehydration, impaired circulation, respiratory problems
Abrasions, cuts, loss of freedom
Death by suffocation or strangulation

Establishing a Restraint Reduction Program

Philosophy
Empowerment of elders and staff
Elders’ dignity and quality of life
Elder safety and freedom within the facility
Policy
OBRA law requires restraints be used only in certain conditions and limitation.
Each facility has its own policy that meets the OBRA law. Know your facility’s policy.

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Know the facility’s alternatives to restraints.
Education
Staff, clients, and families need education on the use of restraints and restraint reduction.
Alternative to restraints should be investigated and selected.
Teaching strategies may include having the facility staff restrained for a short period of time. Few individuals would choose restraints for themselves as a suitable intervention.

Steps to success- Restraint Program

Begins with a multidisciplinary team
Family members should be included because they may continue to ask for a restraint to prevent falls. The family needs to sign a consent for a restraint. Family education is critical to success.
Policies and procedures for applying a restraint and removing restraints should be developed.
Alternatives to restraints should be available in the facility.
After removal, follow-up and assessment of patient safety is needed. Additional alternatives may need to be tried.

Assessment-Restraint Reduction

Documented need for an intervention should be completed first.
Assess posture, alignment, balance, strength, and visual acuity.
Examine head control, trunk stability, upper extremity support, and ability to self-propel if in a wheelchair.
Perform a cognitive assessment.

Consultation-Restraint Reduction

Roles as consultant: Advocate, observer, teacher, information specialist, team problem solver, identifier of resources
Formal restraint reduction training
Development of alternative to restraint use
e.g., splints if indicated
Examine the environment for needs and psychosocial and activity-related alternatives.
Teach the staff alternatives.

Environment- Restraint Reduction

Chair selection: Reclining chairs
Alarms for chairs and beds
Low beds that rest on or very near the floor
Fall mats
Moving furniture away from beds so that rolling out of a low bed to the floor is safer
Wrap-around walkers
Nursery intercoms that can help monitor safe ambulators
Families can help decorate elders’ rooms so they appear familiar and safe.

Psychosocial approaches-Restraint Reduction

Have a written plan of interventions for cognitively impaired elders who may wander.

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The elder may have an agenda behavior that is repeated and can be expected and planned for.
Keys to responding successfully to agenda behavior are to allow elders to act on their plan, find a point at which they will accept a suggestion or guidance, and allow them to keep their dignity.

Activity alternatives-Restraint Reductions

Provide meaningful occupations for elders.
Relate activities to their past occupation if able.
Provide an activity kit:
Sewing basket, briefcase, fanny pack, or tackle box of items that can be manipulated by the elder

Treatment- Restraint Reductions

Self-care techniques
Must be done as part of the elder’s agenda and routine
Upper body positioning
Best support possible is needed. A full lapboard can be used if it doesn’t promote agitation for the elder.
Swing-away lap tray; foam wedges or bean bags
Seating adaptations
Correctly fitted wheelchairs with pads that support elders
Drop seat chairs and reclining chairs that can prevent elders from rising or rising too quickly but do not restrict other movements
Foam pads that support and position elders

Wheelchair Seating and Positioning- COTA must understand

The use of wheelchairs at home, in the community, or in institutions improves the clients’ mobility, level of independence, and participation in their chosen occupations.
One size does not fit all.
Joint replacements, osteoarthritis, osteoporosis, CVA, Alzheimer’s disease, Parkinson’s disease, dementia, diabetes, heart failure, and hypertension can all influence the type, size, and fit of the wheelchair.
Outcome of wheelchair fitting done by OTR
Proper positioning, independence, prevention of skin breakdown, improved quality of life

COTA’s Role in Seating and Positioning

Posture should be monitored continuously.

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Pressure relief to prevent skin breakdown
Elders have very fragile skin, and pressure causes breakdown quickly.
Pressures sores develop when the blood circulation to an area is decreased; sitting in one position for too long can cause this to occur.
Teach elders to monitor their own skin.
Look for areas of redness over bony prominences. Change positions every 1 to 2 hours.
Use a mirror to inspect their skin.

Optimal seating position wheelchair

Pelvis: Neutral position with weight equally distributed between the left and right ischial tuberosities
Trunk: Slight lordosis in lumbar area, slight kyphosis in thoracic area, and small amount of cervical extension
Femurs: Neutral position; slight abduction of the hips; and 90 degrees of flexion at the hip, knee, and ankle
Arms: Supported by armrests but without shoulder elevation

Benefits of Correct Positioning in a Wheelchair

Assists breathing, swallowing, digestion
Improves socialization by changing elder’s eye gaze
Promotes comfort (reduces pain, sliding, leaning)
Provides easy rolls for the client
Insurance restrictions sometimes lead to use of sling upholstered wheelchairs really meant for short-term use only
Insert a solid seat or back.
Add padded cushions.
Adjust the wheelchair if able.

Causes of falls

Environmental
Biological
Cognitive or psychosocial
Functional

Risk factors for Falls

History of falls, neurologic illness
Multiple medications
Poor eyesight, deconditioning
Environmental hazards, poor lighting, loose carpets, no clear walking pathway in the home or room

Fall Statistics

Elders older than 75 years of age fall more frequently than any other age group except infants and toddlers.

Accidents are the sixth leading cause of death for those older than 65 years.

Leading type of accident in the home

One in 40 elders who have fallen will be hospitalized, and only about half will be alive 1 year later.

Causes of Falls

Environmental causes
Poorly kept home or yard
Poor lighting or glare
Uneven stairs, lack of handrails on stairs
Uneven and unsafe surfaces (frayed rug edges, slippery floors in showers and tubs, polished floors, cracks in cement)
Unstable or low furniture (chairs, beds, toilets)
Pets, young children, clutter or electric cords in walkways
Inaccessible items
Limited space for ADLs

COTA’s role in fall prevention

: Inspect the client’s living environment for hazards that may lead to a fall.

Biological causes of falls

Sensory
Visual changes, loss of depth perception, peripheral vision, color discrimination, acuity, accommodation
It becomes difficult to judge the depth of stairs.
Bifocals and trifocals take time to get adjusted to.
Vision
Macular degeneration, cataracts, diabetic retinopathy, glaucoma, and stroke all affect vision.
Spatial organization or figure ground may cause an elder to perceive a change in rug color or flooring as a stair.
Misinterpreting visual information leads to falls.

Cardiovascular
Blood pressure changes
Orthostatic hypotension, neuropathy, diabetes, medication side effects, syncope
Lower cardiac output
Results in lightheadedness, dizziness, impaired venous return; may occur from prolonged bed rest

Neurologic or musculoskeletal causes of falls

Changes in the center of gravity, gait, stride, strength, and joint stability increase the risk for falls.
Changes in posture control include decreased proprioception, slower righting reflexes, decreased muscle tone, and increased postural sway.
Decreased height in stepping
Medical conditions that contribute to instability include degenerative joint disease, deconditioning, neuropathy, stroke, Parkinson’s disease, and dementia.
Musculoskeletal conditions include osteoarthritis and decreased range of motion.

Cognitive or psychosocial causes of falls

Poor judgment, insight, and problem-solving skills
Confusion or inattention
Fatigue, depression, dementia
Drug reactions, fear of falling
Unfamiliarity with a new environment or caregiver
Strong drive for independence

Functional causes of falls

ADLs become challenging
Functional mobility problems
Transferring from bed to chair or toilet, tub, or shower
Reaching, sitting, standing, and walking unsupported
Lack of assistive aids for ambulation or an inability to use them
Carrying a walker instead of using it to walk
Old, lost, borrowed, or smudged glasses impair vision
Poorly fitting shoes, loose pants that drag, and flimsy sandals affect balance

Multifactor causes of falls/preventation

Interdisciplinary team should work together
Not only ask the elders about their routines and ability to perform ADLs; also observe them doing the activities.
Shoes: Wear sturdy, rubber-soled shoes that fit well; slip-on shoes should fit well.
Dressing techniques should be taught.

Fall prevention-limit reach

Limited reach
Use reachers, extended handles on bath brushes, shoe horns, carts, walker trays or bags, or sock aids.
COTAs can determine the best way to attach the reacher to a walker or wheelchair.
Rearranging an elder’s environment is inexpensive and effective in fall prevention.

Fall Prevention-Difficulty with transfers and mobility during ADLs

Safety training with a cane, walker, or wheelchair
Good night lights for elders who get up to urinate at night
Wider walkways by moving furniture or eliminating too much furniture

Bathroom modifications for Fall prevention

Tub or shower bench with armrests and back
Handheld shower hose, grab bars
Raised toilet
Floor mats should have nonskid backing and be in good condition.
Heat-sensitive safety valves should be installed to prevent scalding.
Bedside commode
Good handrails may need to be installed in showers, near toilets, and so on for balance.

Kitchen modifications- Fall prevention

Avoid step stools.
Keep objects within reach.
Provide simple meal preparation guidance.
Use a microwave instead of the stove.

Furniture-Fall prevention

Height of seats can be increased with firm cushions.
Chairs with armrests are helpful.
Chairs with wheels should be avoided.
Elder’s feet should be flat on the floor when seated.

Preventing orthostatic hypotension

Occurs when an elder goes from a lying to a sitting position or a sitting to a standing position.
It is a drop in blood pressure enough to cause dizziness or passing out.
Prevention
Educate elders to sit up slowly and sit for a few minutes before standing.
Elders can dress while seated.
Physician should be informed about this form of hypotension.

Strategies for limited endurance

Place chairs strategically around the home.
Sit while performing ADLs.
Have a commode chair near the bed.
Perform general strengthening exercises.
Try community exercise programs such as swimming, dance, or walking clubs.

Ensure that the elder has access to emergency assistance.

Phones
Phone numbers
Neighbor
Family members

Community Mobility

Pedestrian safety
Alternative transportation
Safe driving

Maintaining Independence in Community Mobility

Driving is an important factor in elders’ independence and mental health.
By 2030, 20% of drivers will be 65 years old or older.
Elders account for a large number of traffic fatalities.
In the past decade, highway traffic fatalities increased by 33% in the elderly population.
Causes: Age-related vision, mobility changes; medications, decreased reaction time, and decreased decision-making skills

Role of COTAs in Elder Community Mobility

Assist elders in being as independent as safely possible.
Help elders identify realistic goals and treatment plans for moving around the community.
Provide resources for transportation when they can no longer drive.
Groceries, pharmacy, medical appointments, activities

Pedestrian Safety

Elders account for approximately 17% of all pedestrian fatalities.
Wheelchairs, walkers, and scooters require more time for crosswalks and may overturn when going down ramps.
A mobility expert should evaluate the type of equipment needed by the elder.
Safety training on the equipment an elder uses is critical for the COTA.

Pedestrian Safety Tips (Box 14-6)

Always use a crosswalk.
Use the pedestrian push button and wait for the WALK sign to appear.
Before stepping into the roadway, search for turning vehicles and look left and right before crossing.
Wear bright (fluorescent) colors during daylight and wear retroreflective material and carry a flashlight if walking at night.

Driver Rehabilitation Professionals

Assist elders needing scooters that are transported in a van.

This professional takes into account the type of wheelchair or scooter, whether the person needing the equipment will be a driver or passenger, and the length of time the equipment will be needed.

COTA’s Role- Driver Rehabilitation

Assist elders in applying for disabled parking placard issues by the Department of Motor Vehicles.
Help the elder determine the requirements for the disabled parking placard.
Paperwork usually needs to be signed by a licensed physician.

Alternative Transportation

Help the elder navigate the public transportation system if one exists.
Call the local senior center.
Independent living centers in the community may also have resources for elders.
Title II of the Americans with Disabilities Act (ADA) addresses elders with disabilities.
Public transportation services are designed to be usable by individuals with disabilities (physical or mental) who need assistance of another to board, ride, or disembark.

Special Transportation Services

Paratransit services: Elders usually must be able to independently leave their home or have someone help them leave the home and enter the paratransit vehicle.
COTAs help elders navigate this paratransit system to secure transportation to appointments and so on.

Visual Acuity

By age 70 years, most elders have poor acuity without corrective lenses or glasses.
This makes driving more hazardous for them.
With aging, changes in the lenses of the eye occur, and the eye muscles weaken.

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Pupil size decreases, which results in not being able to see well at night.
Field of vision decreases with age, and this contributes to collisions. Special mirrors on the car can be used to improve vision.

Glare occurs when too much light or light from the wrong direction is present. Elders’ eyes recover more slowly when glare is present.
Color of traffic lights can be a problem because elders require additional time to read road signs.

Hearing

37% of people older than 65 years of age experience some hearing loss.
Hearing is needed for horns, sirens, train whistles, ambulances, fire trucks, police vehicles, and so on.
Elders may need hearing aids to assist with this problem.

Muscles and Joints

Elders experience back pain, making it difficult to sit for long periods of time.
Arthritis may cause stiffness in the neck, making turning the head limited or painful.
Reaction time is lengthened in elders, making sudden changes in traffic or sudden stops almost impossible.
AARP has courses for elder drivers to improve unsafe habits.
Behind-the-wheel evaluation is the best method to determine driver safety.
Unsafe or questionable drivers should be reported to the DMV in each state.

Cost-control strategies can create ethical challenges for practitioners.

Traditionally, services are based on clinical need.
Increasingly financial constraints may impede care.
Cost-driven practices may include “creative” documentation.
Creative documentation refers to the practice of exaggerating a problem, altering a diagnosis, or implying better prognosis so more client visits can be approved.
When fraud exists, such practices are also liable to legal inquiry and punishment.

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Informed consent hinges on respect for client autonomy and the practitioner’s ability to effectively communicate potential outcomes.
The higher the risk, the more thorough the informed consent process should be.
Autonomy necessitates that they be allowed to accept or refuse the intervention.
Respect for autonomy does not include offering interventions that are not clinically indicated.

Ethical Problem Solving

Stages to ethical problem solving:

Awareness: What is going on?
What kind of ethical problem is it?
Who is involved?
Which laws and institutional rules apply?
What guidance does the AOTA provide?
What are my options?
Reflection: What do I think should happen?
Support: With whom do I need to talk?
Action: What will I do?

What kind of ethical problem is it?

Ethical dilemma = a situation in which there are two or more ethically correct options for action
Ethical distress = a situation in which the COTA knows which course of action to take but feels constrained to not carry it out
Distributive justice = a situation in which there is not enough of something that is valued

Who is involved in ethical decision/problem solving

Usually the COTA
Likely the COTA’s client
The client’s family often needs to be involved in medical decision making.
Family involvement may result in an ethical dilemma for the COTA.

Which laws and institutional rules apply?

Ethical action = making morally good choices
Legal action = right and wrong as a principle of justice
Ethics can be said to hold practitioners to a higher standard than the law.
Laws and institutional rules both help clarify the role of COTAs in a given ethics problem.

What guidance do the Occupational Therapy Ethics Standards provide?

A philosophical and practical translation of how to maintain professionalism in practice.
A regulatory code: guidelines for conduct are stated, and sanctions are provided for failure to comply with the code
Sanctions are stated in the Enforcement Procedures for the Code of Ethics.

Code of Ethics outlines principles for OT practitioners.

They must:
Demonstrate concern for the well-being of their clients and respect their clients’ rights.
Be competent.
Comply with laws and rules that apply to their practice.
Provide accurate information about services.
Be fair and discreet and demonstrate integrity with colleagues and other professionals.

What are my options for conflicts of ethics ?

Conflicts of conscience = conflicts between personal and professional duties in which the ethical course of action is not clear
Ethicists suggest estimating the consequences of a given option weighed against the consequences of other options.
Ethically preferable course of action = action that carries the greatest probability of a good outcome (benefits) and the least amount of damage (burdens)

Reflection: What do I think should happen?

COTAs must decide what they want to happen and must be able to explain their position.
Ethical reflection involves careful and critical examination of feelings and values, a rational estimate of benefits and burdens, and a sense of professional duty.

How free writing can be used for ethical reflection

Write for 10 minutes without stopping.
Key is to suspend the usual breaks in writing and let uncensored thoughts pour onto the page.
Technique is useful in uncovering deep moral and ethical feelings.
Technique may reveal previously unrealized opinions or persuasive reasons for a stance.

Support: With whom do I need to talk for ethical conflicts?

Ethical commitments are shaped by social influences; outcomes of ethical decisions also have social effects.
Before acting according to moral convictions, COTAs should solicit the support of others who will be affected by the issue.
Involved parties generally include:
The client, the client’s family, other staff members, and possibly the organization’s ethics committee

Ethical conflicts Action: What will I do?

COTAs will need to take action; doing nothing can also be perceived as an action.
COTAs may retain uncertainty but take comfort in knowing they gave deep thought to their position.

Ethical conflicts Action: Reporting

Reporting another’s unethical behavior is sometimes referred to as whistle-blowing.

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Reporting another’s unethical behavior can take courage, especially if a COTA’s job is threatened.
If possible, COTAs should work with the support of others, especially those in a supervisory position.
COTAs should make sure to document their actions so their systematic efforts to address the problem are well established.

Ethical conflicts Action: Reporting healthcare professionals

When reporting other health care professionals, the state regulatory board should be contacted.
State boards have the power to intervene if they determine the public to be at risk because of a practitioner’s incompetence, lack of qualifications, or unlawful behavior.
State boards can publicly reprimand a practitioner or may even prohibit someone from practicing in that state.

Ethical conflict action: What will I do professional boards

Three major bodies with jurisdiction over professional behavior:
AOTA Ethics Commission
Responsible for writing the profession’s ethics standards and for imposing sanctions on AOTA members who do not comply
National Board for Certification in Occupational Therapy (NBCOT)
Responsible for certifying OTRs and COTAs
Can permanently deny or revoke certification if necessary
State licensing board

Overview of Cultural Diversity

Each client has his or her own culture with his or her own blend of values and beliefs.
Clients are unique in race, gender, age, ethnicity, physical ability, and sexual orientation.
Their families, place of birth, religion, levels of education, and work experiences are also diverse.
COTAs contribute to the creation of a therapeutic environment where diversity and differences are valued and where elders can work to reach their diverse goals.

What Is Culture?

The contexts that influence performance skills and performance patterns (observable behaviors of occupations)
Include physical, social, personal, spiritual, temporal, and virtual factors that influence occupation
“Customs, beliefs, activity patterns, behavior standards, and expectations accepted by the society of which the individual is a member” (AOTA, 2008).

Culture Is Learned?

Culture is learned or acquired through socialization.
Not genetic
Environment is central to culture.
Shared with others
Cultural beliefs can change over time.
Culture can be subconscious.
Essentially, every belief and value that humans acquire as members of a society can be included in their culture, thus explaining the broadness of the concept of culture.

Levels of Culture

Values and beliefs are shared at a variety of levels.
Individual
Sense of humor, personal space, coping style, role choices
Family
Economic factors, ethnicity, housing
Community
Language, geography, industry
Region
Shared with community and includes language, geography

Ethnicity

Part of a person’s identity that is derived from membership in a racial, religious, national, or linguistic group
Ethnocentricity
The belief held by members of a particular ethnic group that their expression of beliefs and values is superior to that of others
Can be underlying, subconscious beliefs that guide a person’s behavior
COTAs should examine their cultural beliefs and biases.

Diversity

Conformity
An individual or cultural group forsakes values, beliefs, and customs to eliminate differences with another culture.
Examples: Americanizing first or last names, speaking only English, abandoning religious practices or social rituals, not wearing a particular ethnic dress
Bias: “a personal and sometimes unreasoned judgment”
Prejudice: “an irrational attitude of hostility directed against an individual, a group, a race, or their supposed characteristics”
Discrimination: “prejudiced or prejudicial outlook, action, or treatment”
Definitions are from Merriam-Webster’s Online Dictionary at http://www.merriam-webster.com/

Cognitive Style

How information is organized by the client—not an assessment of cognitive function for brain dysfunction
Open-mindedness or closed-mindedness

Open-minded persons:

Seek additional information before making decisions
Ask many questions, listen to alternatives

Closed-minded persons:

See only a narrow range of data and ignore additional information

Associative styles:

Filter new data through a screen of personal experience—only in terms of past experiences

Abstract thinkers deal with new information through ?

imagination.

What Is Accepted as “Truth”

Acts on faith

Acts on fact

Acts on feelings

Acts on faith

Has a belief system based on religion or political ideology and uses it to determine “good” or “bad”
Screen for faith-based beliefs before planning care

Acts on fact

Will want evidence to support the COTA’s treatment recommendations
Will want to know risks and benefits; will ask questions

Acts on feelings

Will go on “gut instinct”; will make a decision based on what feels right instead of facts
These clients need to feel comfortable with the COTA before following therapy recommendations.

Value Systems

separates wrong and good from evil.

Dominant American culture value system

Equality of all people
Informality in interactions with others
Emphasis on the future
Change
Progress
Punctuality
Materialism
Achievement

Locus of Decision Making

The extent to which a culture prizes individualism as opposed to collectivism

Individualism

Degree to which a person considers only himself or herself when making a decision

Collectivism

Degree to which a person must abide with the consensus of the collective group

When making health care decisions, some clients make ___?

their own decisions, others need the collective consensus of a group (family or extended community).

Sources of anxiety reduction

How does the elder handle stress?
COTAs should know who supports the elders in times of stress when decisions need to be made.

Issues equality and inequality

Socioeconomic status, gender, and age are factors to consider when assessing how decision making occurs for the client

Ageism:

Belief that one age group is superior to another
Avoid stereotyping or assumptions about inferiority.

Different use of time, monochronic and polychronic

Monochronic: “One thing at a time”
Adherence to schedules is important
May be offended if kept waiting
Polychronic: Organize their lives around social relationships
May be late to appointments
Enjoy conversation
Want to know the COTA personally

Different communication styles -culture

Cultures differ in the amount of information communicated.
Cultures differ in verbal and nonverbal language.
High-context cultures have understanding through shared experiences and history.
Low-context cultures focus on precise, direct, and logical verbal communication.
Depending on which context culture you are from and which the client or family is from, communication needs to be adjusted so that understanding occurs.

OT Framework

Occupational Therapy Practice Framework Purpose

Framework is intended to help OTRs and COTAs analyze their current practice and consider new applications in emerging areas.
Developed to help the external healthcare professionals (e.g., physicians, payors, community) understand the profession’s emphasis on function and participation in social life.

Domain of concern:

assisting people to engage in everyday life activities that they find meaningful and purposeful

Occupations

(activities) permit the patient to participate in desired roles and life situations in the home, school, workplace, and community.

______ is emphasized as the central characteristic of occupation.

Personal meaning

The framework is used by OTs as a way

of organizing and substantiating their work.

The framework can be applied to the care of

any person needing OT services.

Areas of occupation

ADLs

Bathing/showering
Bowel and Bladder management
Dressing
Eating
Feeding
Functional mobility
Personal device care
Personal hygiene and grooming
Sexual Activity
Toilet hygiene

IADLs

Care of others
Care of pets
Child rearing
Communication device use
Community mobility
Financial management
Health management and maintenance
Home establishment and management
meal pre and cleanup
Religious observance
Safety and emergency maintenance
Shopping

Rest and sleep

Rest
Sleep
Sleep Preparation
Sleep Participation

Education

Formal Educational participation
Informal personal educational needs or interest exploration
Informal personal education participation

Work

Employment interest and pursuits
Employment seeking and acquisition
Job performance
Retirement preparation and adjustment
Volunteer exploration
Volunteer participation

Play

Play exploration
Play participation

Leisure

Leisure exploration
Leisure participation

Social participation

Community
Family
Peer, friend

Performance skills

Motor and praxis
Sensory -perceptual
Emotional Regulation
Cognitive
Communication and social

Motor and praxis

Bending and reaching
Pacing
Coordinating
Maintaining balance
Anticipating or adjusting posture and body position
Manipulating

Sensory-perceptual

Positioning the body
Hearing and locating
Visually determining
Locating by touch
Timing
Discerning flavors

Emotional Regulation

Responding to feelings of others
Persisting despite frustration
Controlling anger
Recovering from disappointment
Displaying emotion
Utilizing coping strategies

Cognitive

Judging
Selecting
Sequencing
Organizing
Prioritizing
Creating
Multitasking

Communication and Social Skills

Looking
Gesturing
Maintaining acceptable space
Initiating and answering
Taking turns
Acknowledging

OT process consists of three dynamic and interactive phases:

Evaluation
Intervention
Outcome

Evaluation

Obtaining the client’s occupational profile
Analyzing the client’s occupational performance

Intervention

Selection of the occupational strategies to meet improve the functioning of the client
Identifying treatment goals and outcomes with the client

Outcome

Measuring the client’s progress toward meeting the treatment goals

Facilitating Growth and Development Model

Views the OT’s role as one “concerned with facilitating or promoting optimal growth and development in all ages of man” (p. 88).
Illness, disability, and trauma threaten an individual’s growth and development.

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The COTA must understand:
Developmental tasks and adaptive skills mastered at different ages
Ways illness, disease, trauma, and disability threaten that development
The environmental variables necessary to support the development and maintenance of adaptive skills

Table 7-3, Characteristics of Maturity Stage of Development

Neurophysiologic and physical development
Psychosocial: ego integrity and maturity
Psychodynamic
Sociocultural
Social language development
ADLs and developmental tasks
Ego-adaptive skills
Intellectual development

COTA’s Role

Assess the client’s developmental stage and potential disruptions in each adaptive skills area.
Analyze the collected data for effects on age-appropriate occupational performance in the areas of work, education, self-care, and play and leisure.

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Devise intervention strategies that facilitate development of a specific skill needed for successful occupational performance.
Sensory, developmental, symbolic, and daily life tasks
Interventions continue until the client reaches sufficient competence in performing the skills and activities described as developmentally appropriate.
Continue to monitor and reevaluate the client’s progress in improving, maintaining, or restoring areas of occupational performance.

Cognitive Disabilities Model

Applies to OT services designed for clients with cognitive impairments.
Cognitive impairments can result from psychiatric illness, medical disease, brain traumas, or developmental disorders.
In this model, “occupation” is synonymous with voluntary motor action (e.g., dressing, crafting, preparing a meal).
Observing a cognitively impaired client’s voluntary motor action gives insight into the relationships among the three domains.

Cognitive Disabilities Model- 6 cognitive levels

describe the way an individual relates matter, behavior, and mind demonstrated by his or her voluntary motor actions
Level 1: greatest degree of impairment
Level 6: normal performance

The COTA can use Cognitive Disabilities model to describe

client performance and to guide selection of activities or tasks that permit the client to function consistently at the greatest possible level.

Task Assessment by the COTA

Information is obtained from the client (if possible) and caregivers regarding the client’s most familiar tasks.
The client is observed performing activities and tasks that are part of his or her daily routines.
The OTR and COTA team can compare the performance with the characteristic behavior for each cognitive level.
Knowledge of the client’s optimal functioning (can also depend on the time of day) helps the team design intervention strategies that maximize the client’s abilities.

Tasks to Assess with Expanded Routine Task Inventory (RTI)

Grooming, dressing, bathing
Walking, exercising
Feeding, toileting
Taking medications, use of adaptive equipment
Housekeeping and doing laundry
Food preparation
Spending and managing money
Communication such as reading, writing, speaking
Following instructions, safety, responding to emergencies

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