Monday, November 20, 2017

What a Gatorade Bottle Taught Me About Functional Assessment



by: Leah B. Rorvig, MD, MS (@GeriPowerMD)

On the third day after my arthroscopic shoulder surgery, I was finally alone at home. My nausea had receded. And I wanted Gatorade. I went to the fridge, pulled out the bottle, and lodged it between my knees. I twisted and twisted with my left hand. I held the lid with a towel. No dice. It wouldn’t budge. Defeated, and still thirsty, I put the bottle back in the fridge. It is still there.

My ADL disability is temporary. I’m in a right arm sling 24 hours a day for the next 6 weeks, during which time I can’t drive or hold anything heavier than a cup of coffee in my right hand. But by next May (6 months from now) my surgeon says I’ll be back to surfing two or three times a week and, best of all, it is very unlikely that I will ever dislocate my right shoulder again (despite my love of sports like surfing and rock climbing). But as a clinical fellow in geriatrics, having a temporary ADL disability has profoundly impacted my perspective on my patients’ functional limitations.

Recently the daughter of a patient of mine (who happens to be in his 90s) told me that he would spend “hours” changing his hearing aid batteries. This gentleman had plenty of support around, and so my immediate response to the patient was “Why don’t you just ask someone to do it for you?” But now that I’ve experienced the shame and frustration of being unable to wash my own dishes—and even my own hair—I can’t believe I would ask such a naïve question so unthinkingly.

Is it necessarily shameful not to be able to wash your own dishes or change your own hearing aid batteries? Of course not. But in our society where self-reliance and independence are core pillars of adulthood, I think I’m not alone in experiencing my own loss of function as a threat to my self-worth.

Curious about what the literature has to say about how we as clinicians should help our patients cope with their declining functional status, I didn’t find much. Yes, I learned that unmet ADL need is associated with all kinds of bad outcomes, including increased risk of hospitalization and even increased mortality. Studies also find that depression in old age is a risk factor for disability, and it is a two-way street - disability is also risk factor for depression. Dissatisfied with what I found, I reached out to one of the leading researchers in my department, and he acknowledged there is very little research on how to manage or improve quality of life among those who already have disability.

What will I do differently as a result of my own unanticipated ADL disability? I’ll stop reflexively minimizing my patients’ functional decline and what it symbolizes. Instead of just asking my patients about their ADL impairments, I now feel I need to also ask about the experience of even having ADL impairments. And then I can begin the real work of understanding what might help those patients who are experiencing distress due to their functional disability. My guess is that it isn’t just an easier to open Gatorade bottle.


2 comments:

Peg Graham said...

Calling attention to mitigating the impact of functional loss! As you point out, there is so much we don't understand about the interaction of losing the capacity to self-manage basic tasks. My family learned how important self-toileting was to our Mom as she aged with post-polio syndrome. With a bathroom too small to accommodate a wheelchair, she selected transfer board-to-bedside commode as her "next best" option, horrified by the thought of swinging in the air in a Hoyer commode swing, or having her children change a diaper. However, she needed us to help her stabilize the board as she inched along, so even there she needed assistance which we all pretended we weren't doing. Upon her death in 2004, my family began to work on an innovative commode, one with an internal lift and tethered board that promotes full self-management of this toilet option. We are working with the TREAT Center, an NIH-funded engineering lab to commercialize this idea, hoping to attract a manufacturing partner.

We have also run into the scarcity of research into ADLs, their interactions and how relief of one might impact the others, and the overall relationship with depression and quality of lift.

THANK YOU for this post, and we join your call for more research into this question. Given the caregiver gap that will only get worse, knowledge and science about functional independence at the individual ADL level is more important than ever.

Anonymous said...

Thank you for this post. Using my own difficult experiences and chronic health challenges to have deeper understanding of and empathy with patients has been very beneficial - both for my patients and for me.