Case Study: Barbara
Several months ago, a woman named Barbara was admitted to the facility where I work. Barbara has dementia and her family decided that it was time to transition to a long-term care facility. At her assisted living facility, she used a four-wheel walker for mobility and completed her mobility and self-care with supervision, but she was starting to fall more frequently.
When I completed her occupational therapy evaluation, I found that Barbara was functioning at Allen Cognitive Level 3.4 and needed close contact-guard assistance to safely complete mobility and self-care tasks. Her physical therapist completed an assessment of her balance and found that she was a high fall risk. Because of this, the physical therapist recommended that Barbara use a standard walker for all of her mobility. She issued Barbara a standard walker and removed the rolling walker from her room.
When Barbara’s daughter came for a visit, she approached us frustrated because both Barbara and her daughter wanted Barbara to use her four-wheel walker for mobility and we had taken it away. The nurses and aides that worked with Barbara were also upset. Because Barbara didn’t recognize the walker in her room and couldn’t find her familiar walker because it had been removed from the room, she was walking without an assistive device and they were worried she would fall. It was up to me and the physical therapist to help to resolve the frustrations of Barbara and her daughter and the concerns of the nursing team.
We started by explaining to Barbara’s daughter that her balance assessment indicated that Barbara was at a high risk for falls and that four-wheel walkers are less stable and therefore not recommended for Barbara unless her balance improved. The physical therapist educated the daughter on Barbara’s plan of care for physical therapy, which included exercises and training to improve her balance. I also educated her daughter on Barbara’s Allen Cognitive Level, which meant that we would need to practice a task with Barbara for approximately 3 weeks before she would be able to incorporate it into her routine. I also shared with her daughter my hope that Barbara’s balance would improve, and she would return to using the four-wheel walker, but my in experience many people eventually need to use a standard walker as their health declines. I explained to her that if Barbara eventually did need a standard walker and her cognition declined further, we would have less success teaching her to use a standard walker at that point. Barbara’s daughter agreed that using a standard walker would be safer for the time being, and beneficial for the future if Barbara had further mobility or cognitive declines.
In order to address the nursing team’s concerns, I worked with Barbara to create a striking visual cue to orient Barbara and her staff to her new walker. We selected her favorite color paper and wrote her name and room number in large bold print on both sides of the paper. I placed the paper in a sheet protector, taped the open end closed, and zip tied the sheet protector to the bars of the walker. Over several treatment sessions, we practiced orienting to and consistently using the walker. I reinforced this behavior whenever I saw her in the halls, and I trained staff so that they could reinforce this behavior as well. Although it took many weeks of consistent practice, Barbara eventually recognized and used her walker consistently in her room and throughout the facility.