Objectives Challenges commonly encountered by people with - - PDF document

Optimizing Care of Patients with Disabilities

• Visual Impairment
• Mobility Impairment

Nathaniel Gleason, MD

Assistant Clinical Professor of Medicine Division of General Internal Medicine

Objectives

• Challenges commonly encountered

by people with disabilities in clinical care

• The difference between disability

and illness

• What can disability advocates teach

us about our broader patient population?

Objectives

• People with visual impairments
• People with mobility Impairments
• Cultural competencies
• Accommodations in the clinical setting
• Important adaptive strategies

How can we talk about “culture” and disability?

“People with disabilities do have a distinctive culture, founded on their shared history of discrimination and common experiences of stigmatization, poverty, social isolation, lack

• f self determination, and “imposed

immobility” — all of which combine to produce a common sense of identity”

–Woodard, Havercamp, Zwgart & Perkins (2012)

Spectrum of Identity

E s t a b l i s h e d D x . M a y i d e n t i f y a s d i s a b l e d . O f t e n k n

• w

s m

• r

e t h a n w e d

• .

Chronic disease with an evolving mobility impairment. Declining mobility. Unaware / unacknowledged.

Blindness and Visual Impairment

The “sighted-guide” technique The “sighted-guide” technique

Cultural Competencies

• Announce yourself
• Announce your departure
• The group conversation
• Be precise with directions
• The clock face

Clinical Accommodations

• Announce physical contact
• Assist with paperwork in private
• Ask about reading format
• Braille and large-type pharmacy

labels

Getting to know your patient

• Blind does not mean total loss of

vision

• “Legal blindness” tells us fairly little
• 20/200 or field < 20 degrees
• Method of reading?
• Orientation and mobility?

Adaptive strategies for reading

• Digital Magnification
• Closed circuit television (CCTV)
• Adaptive computer software
• Large print
• Audio
• Bookshare
• Newsline

Adaptive strategies for “Orientation and Mobility”

Orientation and Mobility

“The white cane tells me everything I need to know about my surroundings.” “It represents independence.” “A signifier that does the explaining”

US Census Definition: Difficulty performing

• one or more functional activities

(seeing, hearing, speaking, walking lifting/carrying);

• preforming ADLs (getting out of bed,

bathing, dressing, eating, toileting);

• instrumental ADLs (keeping track of

money and bills, preparing meals, housework, prescriptions meds; …

• mental or emotional condition that

seriously interfered with everyday activities (learning disabilities, developmental disabilities, dementia, and mental illness)

Disability

Pathology Functional Limits

Macular degeneration Decreased visual acuity Can’t read small type Can’t read Rx on bottle

Impairment Disability

Disability is a complex interaction between the health condition of the individual and the contextual factors

• f the environment. -WHO

Of the 38,000,000 seniors on Medicare…

• 12 million (31%) are fully independent (without

accommodation, difficulty, or help) for self-care and mobility

• 9 million (25%) successfully adapted to disability
• 2.1 million (6%) have reduced activities without

acknowledging limitations

• 7 million (18%) report difficulty but not assistance
• 7.7 million (20%) received assistance with ≥ one

task

Prevalence of Visual Impairment

• 7.7 million adults have difficulty with

newspaper print;

• of these, 1.8 million have no

functional vision.

Language

• Evolving
• Handicap
• Disabled
• People with disabilities
• Visually impaired, low-vision,

legally blind partially sighted, totally blind

Language

“Where have you been? You must not know very much about my disability.”

Language

“How do you pronounce your name?”

Disparities in Care

• Increased susceptibility to secondary

health problems

• Disparities in access
• Lower rates of preventive services
• Poorer health outcomes
• Important intersection with poverty

Minkler M et al. New England Journal of Medicine 2006

g

Poverty Status by Disability Status: 1997

Source: U.S. Census Bureau, 1996 Survey of Income and Program Participation: August - November 1997.

(Age 25 to 64 years, percent in and out of poverty) 72.2 89.6 91.7 27.9 10.4 8.3 No disability Not severe Severe In poverty Not in poverty

Mobility Impairments

Cultural Competencies

• A wheelchair is considered

personal space

• Place yourself at the patient’s

eye level when talking for more than a moment.

• Is a transfer to the exam table

necessary?

Language

• Wheelchair bound
• Confined to a wheelchair
• Wheelchair user
• Mobility

Screening

“Timed Up and Go” (TUG) Test

• a. rise from chair
• b. walk 10 feet
• c. turn around
• d. return to seated position

>12 seconds = risk of falls

Mobility Aids

• Improve safety
• Decrease pain
• Decrease energy expenditure
• Restore independence

Standard cane Offset cane Quad cane

Canes

Proper fitting of canes & walkers

• Align with the wrist crease

(with arm relaxed at side), wearing typical shoes

• Elbow flexed 15-30 degrees

while walking

Social stigma & mobility aids

• Reframe the issue
• Describe the aids as tools
• “increased mobility”
• “maximize potential”
• Not all or nothing.

Take home

• Disability = Functional Limit +

Environment

• Address disability independent of the

pathology

• e.g. add mobility to the problem list
• Cultural competencies exist and can be

mastered