Case Study: Margaret
I received orders to evaluate Margaret, a long-term resident at my facility, because the nursing team reported that she has been requiring more assistance to feed herself. I reviewed her chart and talked to her day nurse and found out that she was having increased pain about a month ago. At that time, because she has difficulty remembering to ask for medication, her doctor prescribed her a scheduled dose of a narcotic. Since then, her pain has improved but she has been noted to have decreased appetite, need for more assistance during meals, and episodes of hypoglycemia. In addition to the referral for an OT evaluation, the doctor reduced the dose of pain medication that Margaret is receiving but kept the dose scheduled regularly during the day.
When I observed Margaret in the dining room, I noticed that she was set at a table alone, facing a TV which was loudly playing music. The other residents were seated at another table with a staff member to assist in feeding them as needed. The dining room was small and crowded, partially blocked off due to a remodeling project. Her food was served to her by an aide who set it out on the table in front of her along with utensils wrapped in a napkin and then quickly moved on to continue serving food to other residents. Another aide began helping the residents at the other table. I watched and waiting for an aide to start helping her, or for her to initiate feeding herself, but after five minutes I jumped in myself.
I started by greeting Margaret and asking what we were having for lunch. She explained that the beef stroganoff in front of her is one of the good meals. I unwrapped her utensils from the napkin and asked her if she wanted to use a spoon or fork. When she didn’t respond, I selected the fork because it would allow her to stab the meat and placed it in her hand. I verbally encouraged her to take a bite. When she didn’t respond, I waited about ten seconds then invited her to get some food on her fork so that she could take a bite. I again waited about ten seconds then gave her the verbal cue to get a bite while providing hand over hand assistance to raise her hand to the plate. Once her hand was to the plate, she stabbed the meat and placed it in her mouth.
After she got started, Margaret was able to feed herself 3-4 bites at a time before she set down her fork and stopped eating. However, by this point the aide helping the other group started checking on Margaret. He gave her a verbal prompt to keep going whenever she put her fork down and she was able to eat a good portion of her meal.
As I was discussing the evaluation with my Level II Fieldwork student, I admitted something to him that I am a bit ashamed of. I told him that earlier in my career, I likely wouldn’t have picked this resident up for therapy services. I would have noted that she has adequate range of motion, strength, and coordination for self-feeding. I would have described her cognitive deficits, but I would have included that they were baseline deficits and therefore they didn’t indicate a need for OT services. I would have observed that her deficits were caused or exacerbated by a medication change and that a second change had been implemented to address the decline. I would have concluded that there was nothing OT could do to help, and the aides just needed to spend the time to help her in the dining room. And I would have been wrong. But today I did better. I set goals for Margaret to initiate self-feeding with less cuing, continue self-feeding with less interruptions and less cuing, and for her aides to be able to cue her at her cognitive ability level. And I ensured that my student and the COTA we work with both caught the vision of what we can accomplish and felt confident intervening to make it happen.