Treating patients with dementia

A 93yo female presented to my ward with a left fractured head of humerus and a left fractured tibial plateau, both injuries were being treated conservatively and the patient was unable to ambulate. It was also mentioned in the patient’s current medical conditions that she had dementia. The patient had undergone a general anaesthetic to realign the head of humerus and as a result had a left lower lobe collapse. My main aim of the treatment session was to educate and teach the patient SMIs.

On the first meeting with the patient, they were in good spirits and very cooperative within the session, I began to question the diagnosis of dementia. However, the next day the patients presented with clear signs of dementia and would not cooperate within my session. I had begun the session the same as the previous day by explaining what I would be doing. I then proceeded to ask the patient to do some SMIs, however the patient refused and held their breath. I tried again to explain why they needed to do the breathing exercises and yet they continued to hold their breath every time I asked them to take a deep breath. By this stage, I was getting very frustrated and annoyed that the patient refused to do such a simple exercise. After 10 minutes of trying to get the patient to cooperate, I gave up and said I would be back tomorrow. The next day when I went to treat the patient earlier in the morning and they were very cooperative and did everything that I asked.

The dilemma raised from this experience is; people with dementia if they refuse physio treatment do you keep trying to convince them on the benefits and hope that they will change their mind or do you just leave the session for that day.

I HAVE LEARNT THAT WHEN TREATING PATIENTS WITH DEMENTIA THE TIME OF THE DAY WHEN YOU SEE THE PATIENT CAN BE IMPORTANT FOR THEM TO BE COMPLIANT. PLUS WITH THIS PARTICULAR PATIENT WITH DEMENTIA THERE IS ONLY SO MUCH EDUCATING YOU DO AND IF THE PATIENT STILL REFUSES TO ALLOW PHYSIO THEN THERE IS NOT MUCH ELSE WE CAN DO. GIVEN THE ABOVE SENARIO AGAIN, I WOULD ACT THE SAME AS ABOVE HOWEVER WOULDN’T GET ANNOYED AS I WOULD KNOW THE NEXT DAY THE PATIENT MAY BE LUCID AND COOPERATIVE. DOES ANYONE HAVE ANY OTHER SUGGESTIONS OF STATEGIES TO TREAT PATIENT WITH DEMENTIA?

Interpret This...

On one of my previous placements where i was seeing musculoskeletal outpatients a patient was booked in for me to see who spoke no English. In the past i have seen patients who speak broken English but never any patient who speaks hardly any English at all. To help with this an interpreter had also been booked to assist with the treatment session this again was not like any other treatment session i have experienced in my physio endeavours.
With a full subjective required to gain information on the patients problems i had no idea how i would be able to find out enough information to treat a problem, and i was unsure of whether to direct my question to the interpreter who would understand them or to the patient who would have no idea of what i was saying in English.
On discussing this with one of the physios at the clinic they informed me it was still important to direct the questions at the patient as it was they who have come to seek treatment and not the interpreter, the interpreter was only there for help in translating the questions to the pateint so they could understand them and then also translating the patients answer so a clear picture of the patients problem could be ascertained.
So through directing the questions to the patient I think a better report was developed with the patient and in the end i was able to carry out a full subjective and objective examination gaining all the information required and then treat the patient with good results, and with seeing the patient several times i was even able to pick up some words in the patients language which i could use say in describing pain or movements and i think the patient appreciated that this was done.

IN THE FUTURE WHEN THE SITUATION ARISES I FEEL I WILL BE MORE CONFIDENT IN BEING ABLE TO TREAT THE PATIENT AS I WOULD ANY OTHER, THAT IS THROUGH ASKING THE EXACT SAME QUESTIONS TO THE ACTUAL PATIENT (INTERPRETERS ARE GREAT TOO). AND EVEN THOUGH THE PATIENT DOES NOT UNDERSTAND WHAT YOU ARE SAYING, ENGLISH BACK PAIN IS THE SAME AS SPANISH BACK PAIN

communication goes a long way

One of my placements was in a surgical ward and a lot of what we did in the ward was to get patients ambulating as early as day one post surgery. Majority of the patients there had gastrointestinal tract surgery whereby some required part of their bowel removed and a colostomy bag placed insitu. A colostomy is a pouch that collects feces and is situated at a surgically-created opening in the large intestine where it bypasses the rectum. It is usually a life changing event for many who had undergone this surgery as it leaves them with the inability to empty their bowel naturally and also the need to learn a new skill of managing their stoma bag. In the five weeks I was there, I met patients that dealt with the new change in so many different ways. Many were not very positive about the change an worse still some was very frustrated that they now have an extra “burden” in their life. Mrs A was my patient in the first week of my placement. It was so easy at this early stage of the prac to just get in there and do what I had to do and not pay much attention to the patient as an individual. Mrs A had bowel cancer and underwent surgery to remove part of her bowel, which had left her with a stoma bag. My goal of treatment for day 1 post surgery was to get her out of bed and ambulating for 30m.When I met her I first introduced myself as a PT student and gave her a brief explanation of the treatment session for that day. She was not very responsive to what I had to say and looked unhappy. So, I asked if it was alright for me to begin and she ignored me. Then, I explained further on the importance of ambulating after a major surgery as such. The patient then replied “fine, just get on with it” in a rude tone. All throughout the assessment and treatment, Mrs. A was very reluctant to participate in the session. Although she did not respond well to instructions and was very passive throughout the treatment session, I still went ahead with the treatment as I felt the pressure of performing in front of my supervisor that happened to walk in that very moment as well as trying to keep time with the treatment session. In my mind there was only one thing I wanted to achieve with the patient and that was to get her out of bed and ambulating and I just did what I had to do to achieve that without any consideration of all the other emotional aspects that she might be going through at that point of time. I walked away from that session that day thinking I have achieved my goal of trying to get the patient ambulating but still felt discontented with the session, as if something was missing.
The next day, when I went to see the patient again, she seemed unsettled, anxious and just was not happy to see me as she recognized me from the day before. Then I just decided to have a sit down and have a chat before I started her assessment. I started having a casual conversation with her and asked her how she is feeling and coping generally. She started opening up to me bit by bit and I discovered that she was not coping very well with the new change but kept it to herself. She feels like she is all alone and no family to turn to for support, care and encouragement. Then I recommended that she talk to a counselor to discuss some of the issues that is bothering her. Just by talking to her this time, I felt like I was more in control of the session as she complied with the session better following the talk. I was able to achieve my goals for the treatment session that day feeling as if I have really accomplished it well this time.
I HAVE JUST REALIZED HOW COMMUNICATION GOES A LONG WAY IN TERMS OF ACHIEVING THE TREATMENT GOAL FOR THIS PATIENT. IN THE FUTURE THEREFORE, IF I WAS CONFRONTED WITH A DIFFICULT PATIENT, I NOW HAVE LEARNED THE IMPORTANCE OF TREATING EACH PATIENT AS AN INDIVIDUAL AND TO TAKE A MOMENT TO IDENTIFY THE PATIENTS PROBLEMS BEFORE COMMENCING TREATMENT IN THE HOPE OF CREATING BETTER PATIENT COMPLIANCE IN ACHIEVING INDIVIDUAL PATIENT GOALS.

Diversity of Clients

I am currently on an outpatient’s placement. A 16 year old girl presented to the clinic post surgery following a # of the base of the 5th metacarpal. The injury came as a result of the client punching the wall after being involved in an argument with her mother. The physiotherapist treating the client introduced the client to myself and asked if she minded if I could perform a subjective examination. The client responded abruptly and commented “oh if she has to”. She attended with her friend who appeared the same age and her mother who remained in the waiting room. Initially I was taken back by the comment and how she had responded to the idea and laughed at her friend. I felt intimidated and nervous about completing the Ax as the client displayed a very negative attitude that suggested that she did not want to be there. The subjective Ax took place with very little compliance from the client with answers to the questions being ‘does it matter’ and ‘I don’t know, who cares’. I finished the Ax feeling like I had not accomplished the task adequately and felt dishearten on the responses I received from the client. I tried to remain professional and friendly and booked a another appointment with the client.

Speaking with the Physiotherapist after the Ax, I believed that the presence of her friend worsened the scenario. Further the PT stated that whilst making a hand splint for the client, she was very protective of her hand and constantly was saying ‘don’t hurt me, don’t hurt me’ which could suggest the client responding to be tough due to being placed into a vulnerable position. A suggestion for the mother to sit into the next session was advised.

It is valuable experience dealing with an array of different clients especially clients that are not compliant towards PT treatment. From this situation I now realise that it requires different and similar skills, such as conformity towards the individual client, integrity and remaining focused, to deal with a non compliant adult vs. teenager. I am also now more aware that showing that you feel confident in what you are doing, even though you may not feel 100% confident can build a professional rapport between you and the client.

If place in a similar scenario, I will try to be more assertive and direct with the way I approach the question, whilst trying to observe the methods that elicit a positive. It highlights that not all clients you treat will respond to you as a health professional in a positive way.

Upset children

I am currently on a pediatric placement in the area of oncology. I am seeing a sweet 11 year old boy as an outpatient who had a brain tumour 5 months ago which has since been removed and treatment has finished. However his outcome from the treatments is a grey area and whether he is cured has not been confirmed. I am treating him for general strengthening, cardiovascular fitness, balance and coordination. His mum brought up that he got pins and needles in his left arm and leg whilst at school that day. She then went to tell his doctor whilst we kept doing physio. Whilst mum was gone for 15mins he continued to be talkative, however as soon as mum returned he immediately got teary and said he didn’t want to do the exercises.

When he got upset it shocked me because it felt like it came out of nowhere. I knew he wasn’t upset at me or about the actual exercises since he’d been doing this personalized exercise program for a few weeks now. I tried to find out from him why he was upset, but he didn’t say, so I asked him if he’d want to play some balloon tennis, which he immediately responded positively to and the tears were gone within seconds. Whilst playing tennis he was back to being talkative and laughing, and opened up to myself and his mum that he was worried about the pins and needles he had felt in the day and this brought back concerns about his cancer returning.

Dealing with an upset child and getting them to share their concerns is different from an upset adult who is more likely to verbalise their issues. I think it was important to try finding out why he was upset, and show empathy. Children won’t necessarily talk when they are crying, hence the change in tactic by playing something fun and cheering them up first. I also learnt that children can come across as seeming emotionally stable but may in fact have an issue bothering them.

From this experience I reflected that many aspects can make a child emotional. It could be one or a combination of things that upset them or possibly even nothing at all that can make them cry. In future I will be less shocked when a child cries during a treatment session unexpectedly. Comforting a child INITIALLY, WHICH may involve distraction strategies, and then later finding the underlying issue upsetting the child, would be my approach in a similar event.

Communicating rationale for treatment with patients

On my musculoskeletal outpatient placement I encountered a client who presented to the department seeking treatment for a recently sustained shoulder injury, however on questioning the patient also stated a number of different painful areas- the cervical spine, lumbar spine and knee. When questioned further, the client stated his main problem was his knee pain which had been present for a number of years. Therefore between the supervisor and myself a decision was made to initially concentrate on the knee problem. We decided this as there was not adequate time to assess each problem since both the shoulder and knee indicated a degree of referral from the spine. This decision was discussed with the patient and he agreed to proceed with this line of thinking. However as the assessment and treatment wore on I started to pick up on non verbal cues that indicated the patient was not happy with this direction and would have preferred us to concentrate of the shoulder. Throughout the session I became increasingly uncomfortable as I felt the client was not satisfied with the direction of the session and this started to lower my level of confidence in my treatment. This situation arose due to miscommunication between myself and the patient as to expectations from physiotherapy treatment.

Previous to this incident I would have assumed the question “what is your main problem?” would be sufficient to direct assessment in a direction satisfactory to the client. Due an assumption made by myself and my supervisor, the patient may have been unhappy with the level of treatment he received.

IN THE FUTURE I WILL ENSURE PATIENTS WHO PRESENT WITH MULTIPLE SITES OF PAIN ARE DIRECTLY ASKED WHICH PROBLEM THEY WOULD LIKE TO BE ADDRESSED FIRST TO ENSURE NO MISUNDERSTANDING OCCURS. THIS ENCOUNTER EMPHASISES THE NEED FOR A THOROUGH EXPLANATION OF THE THOUGHT PROCESSES BEHIND OUR ASSESSMENT AND TREATMENT TO IMPROVE PATIENT’S CONFIDENCE IN OUR INTERVENTIONS. IT ALSO HIGHLIGHTS THE NEED FOR PATIENT INVOVEMENT IN DECISION MAKING AND GOAL SETTING.

PATIENT CONFIDENTIALITY

On inpatient neurology placement I treated a lady who had been in hospital for 6 weeks following myelinopathy secondary to substance abuse. The pt responded well to treatment and this was her last PT treatment. The aim was to continue with her exercises and put into place any community services the patient requires.

While conversing the pt voiced her wishes of maintaining confidentiality of her diagnosis. I reassured her of patient confidentiality and continued physio, paying close attention not to discuss any information with the pt outside her room or with other PTs on the ward and physio gym. The pt's exercises were progressed and the patient was referred for community physio. I informed the patient I would return in the afternoon with her referral.

I filled out her referral diagnosing her condition as a “myelinopathy secondary to substance use” consistent with the neurology team. On returning to the patients room there was a visitor. I subsequently gained consent to enter and start physio and gave her the referral, to sign for consent. She read the form, and asked her visitor if she could leave the room. Following the visitor exiting the room the pt expressed her disappointment on my part of for writing on the referral her diagnosis and anxiety as to whether the diagnosis form had been seen by her visitor. I reassured the patient that the form was standard protocol for referrals and that all staff working in the outpatient physio also maintain patient confidentiality.

FOLLOWING TREATING THIS PATIENT, IT HIGHLIGHTED THE IMPORTANCE OF PATIENT CONFIDENTIALITY. THE PATIENT OBVIOUSLY DID NOT WANT PEOPLE IN THE COMMUNITY FINDING OUT ABOUT HER CONDITION. I REASSURED THE PT THE CONFIDENTIALIY IS MAINTAINED IN ALL HEALTH SETTINGS NOT JUST IN HOSPITALS. IF I WERE TO TREAT A PATIENT WITH SIMILAR CONCERNS IN REGARDS TO CONFIDENTILAITY I THINK IT WOULD BE IMPORTANT TO ENSURE ALL VISITORS WERE EXCUSED FROM THE ROOM, CONDUCT THE PT SESSION IN A PRIVATE ROOM OR EMPTY GYM, AND TO TAKE THE TIME TO EXPLAIN THE REFERRAL PROCESS AND FORM TO THE PT TO RELIEVE THE PT OF THEIR CONCERNS.

Using the team

I'm on my general surgery placement for cardio. A 73 year old male underwent a laparotomy 2/52 ago. He constantly refused ambulating with the nurses and physios. He also refused any input from physio and OT. We tried educating him on the dangers of prolonged bed rest, and even asked his partner to encourage him to ambulate, but he still refused. He occasionally sat out of bed in the chair, and only transfered to a commode for the shower, but most of the time was spent lying in bed.


It was very difficult to get this patient ambulating, and it would only get harder as time went on. After communicating with his nurse, OT, and my superviser, we decided on all of us to encourage him to ambulate to the shower. Through this, the physio and OT will have a better idea of his mobility, he would have had the exercise he needed, and have a shower aswell. Through this combined effort, I feel it gave us more control of the situation, therefore, making the patient less resistant. We managed to get him ambulating to the shower, which was the furthest he'd walked. I have not seen him since, but in my next session, hopefully he will be aware of what he is capable of doing, and be more compliant with physiotherapy.


USING A COMBINED EFFORT WITH THE WHOLE TEAM IS VERY EFFECTIVE, ESPECIALLY WITH THOSE PATIENTS WHO ARE NOT COMPLIANT. THIS TECHNIQUE NOT ONLY PROVIDES MORE MOTIVATTION TO THE PATIENT, BUT ALSO IS MORE EFFICIENT FOR THE STAFF (IE THE PATIENT HAD HIS PHYSIOTHERAPY AND OT INPUT, ASWELL AS A SHOWER ALL AT ONCE). WHEN COMING ACROSS A SIMILAR SITUATION IN THE FUTURE, I WILL COMMUNICATE WITH THE WHOLE TEAM REGARDING THIS SITUATION, TO TRY AND WORK OUT A SOLUTION TO NOT ONLY GIVE THE PATIENT THE REQUIRED INPUT FROM THE ENTIRE TEAM, BUT ALSO TO MANAGE TIME EFFICIENTLY.

Taking control of a session

A 60 yr old male presented to my ward after having an ORIF on his ankle after suffering a distal fibular fracture 7 days ago. Distal fibular fractures are usually treated conservatively, so when reading the notes I began to wonder why this patient had his injury treated surgically. My aim for the session was to do a subjective and objective assessment and to teach the patient how to use A/C crutches. During my assessment I learnt that the reason this patient had an ORIF on his ankle was because he got a cast on his ankle 5/7 ago and when he got home he decided the cast was to tight so instead of going to hospital he decided to take it off himself, I also learnt that he had been given crutches and had been ambulating on them before the ORIF. So I assumed the patient would know how to use the crutches properly and gave them a brief reminder of how to use the crutches.

As soon as I got the patient ambulating with A/C, he did not listen to any of my instructions about slowing down or about how to turn and as a result nearly fell over twice; I was the only thing that stopped him from falling. By the end of the session I was very stressed as I felt I had lost complete control of the situation; and I didn’t know how to get the patient to listen to my instructions.

After the session I knew I was not clear with my instructions and that I needed to find a way to stop the patient from controlling the session as I deemed it unsafe. Upon reflection I knew next time with this particular patient I would have to come across very confident but I also had to be very clear with my instructions and if the patient didn’t do what I had asked, I was to stop him and explain again what I was expecting.

During the next session with this patient I clearly and confidently explained from a physiotherapy perspective how to use the crutches, how fast I wanted him to ambulate and that if I asked him to change an aspect of his ambulation technique it was for safety reasons and that I expected him to comply. I feel that the key to achieving a safe ambulation technique with this patient was to take complete control on the session and thorough explanation of the consequences was required to get the patient to adopt the correct ambulation technique.

IN THE FUTURE I WILL GIVE A THOUROUGH EXPLAINATION OF CRUTCHES TECHNIQUE AND SAFETY CONCERNS WITH ALL PATIENTS. I AM NOW MORE AWARE THAT SOME PATIENTS ONCE AMBULATING WITH CRUTCHES IGNORE THE PHYSIOTHERAPISTS INSTRUCTIONS AND THAT AS SOON AS I NOTICE THIS CHARACTERISTIC I AM TO STOP THE PATIENT AND EMPHASIS THE IMPORTANCE OF THEM FOLLOWING MY INSTRUCTIONS.