Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Disability
Disability - Key Features
1. Determine whether a specific decline in functioning (e.g., social, physical, emotional) is a disability for that specific patient.
2. Screen elderly patients for disability risks (e.g., falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.
3. In patients with chronic physical problems (e.g., arthritis, multiple sclerosis) or mental problems (e.g., depression), assess for and diagnose disability when it is present.
4. In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
5. For disabled patients, offer a multi-faceted approach (e.g., orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
6. In patients at risk for disability (e.g., those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (e.g., exercises, braces, counseling, work modification).
7. Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan).
What is Disability:
“because of disability” means for the reason that the person has or has had, or is believed to have or have had,
- (a) any degree of physical disability, infirmity, malformation or disfigurement that is caused by bodily injury, birth defect or illness and, without limiting the generality of the foregoing, includes diabetes mellitus, epilepsy, a brain injury, any degree of paralysis, amputation, lack of physical co-ordination, blindness or visual impediment, deafness or hearing impediment, muteness or speech impediment, or physical reliance on a guide dog or other animal or on a wheelchair or other remedial appliance or device,
- (b) a condition of mental impairment or a developmental disability,
- (c) a learning disability, or a dysfunction in one or more of the processes involved in understanding or using symbols or spoken language,
- (d) a mental disorder, or
- (e) an injury or disability for which benefits were claimed or received under the insurance plan established under the Workplace Safety and Insurance
Based on Ontario Human Rights Commission
A. History
HPI:
MSIGECAPS
DIMS FU ==
- Drugs (intox or withdrawal)
- Infection (chest, GU, skin/soft tissue)
- Metabolic (endocrinopathy [DM, TSH], electrolytes (Na, K, Ca), renal or liver failure
- Structural (stroke, hemorrhage, seizure, neoplasm)
- Fecal impaction
- Urinary retention
SOC Hx:
Smoking/EtOH/Street Drugs/Caffeine
Check for ADLs (DEATH == Dressing, Eating, Ambulating, Toileting, and Hygiene)
Check for IADLs (SHAFT == Shopping, Housework, Accounting, Food Prep, Transportation)
Financial Support
Family Support
Employment or Social Outlet
± Advanced Directive
ROS:
Falls in the elderly: affected by the following:
• orthostatic hypotension,
• meds,
• environmental hazards, and
• medical conditions affecting gait, balance, vision, strength, and proprioception.
- The single best predictor of a fall is a prior fall* -> 50% of seniors will go on to another fall within 12 months of their first fall
B Physical:
Visual Acuity (typically done in CPX), sometimes annually with Ophthalmologist
Weight and Height (typically done in CPX) (> 2 cm drop indicates vertebral fracture)
PHQ-9 (or Geriatric Depression Scale – GDS) scores to assess decline in emotional aspects of life
MMSE for monitoring dementia
Postural Vitals: Lying, Sitting, and Standing (waiting after five minutes to detect orthostatic changes); Temperature
H&N: Cataracts, CN-exam, LAD, Thyroid
Resp: Symptoms of COPD
CV: New murmurs, bruits, collateral circulation
Abdomen: DRE (with sphincter tone)
GU: rectocele, vesicocele
Neuro: gait, balance
MSK: joint ROM, atrophy, weakness, some focus on feet (callus, corns, abnormal nails)
Skin: Suspicious Mass
(Timed) Get-up-and-Go Test (for mobility and falls assessment):
Person stands from a seated position and walks a distance of 3m (10 ft), turns, and walks back to the chair and sits down.
< 10 sec is mobile, no impairment
> 30 sec is significant impairment
C Diagnosis
Refer to What is Disability section.
D Treatment and Interventions:
For Disabled Patients: (the key is a multi-faceted approach)
Conservative:
- • Those who are employed will need time off work.
- • Impaired mood will need counseling (eg CBT) and community programs.
- • Pain will need to be controlled using the WHO Pain Ladder
- • Mobility needs to include orthotic, walker, or wheelchair (O/T)
- • Appropriate exercises to prevent further decline (P/T)
Non-conservative:
- • Medications, injections, dialysis etc
- • Surgery, ECT
For at risk for disability:
(targeted preventative maneuvers are not as effective as multi-faceted approaches)
- • Influenza and Pneumococcal Vaccine for seniors
- • Reducing or eliminating offending medications
- • Improving visual acuity
- • Improving footwear, or referral to podiatry
- • Use of adaptive devices, such as arm supports, protective rails, walking aids
- • Balance exercises, coupled with moderate physical activities -> careful with recommending too much physical activity as this may increase the risk for disability); Core stabilization.
- • Socialization
- • Hip protectors for the frail elderly -> but best to avoid the fall, rather than the impact of the fall
- • Improve the home environment: better lighting, fixing damaged floors, etc.