Consider this hypothetical situation: Mr. Jones was admitted to SNF after falling (hip fracture) on a small patch of ice outside their favorite restaurant where he has a weekly dinner date with his daughter. At initial screening, SLP determined Mr. Jones presented no changes in cognitive, language, speech, or swallowing function. Mr. Jones has memory impairment (at baseline) and lives in an assisted living facility. SLP wrote up the screen and recommended that therapy or nursing follow up with SLP if Mr. Jones’ memory impairment impacts ability to participate in nursing or therapy tasks.
A week and a half pass and Mr. Jones is feeling much better. He’s been really engaged in physical and occupational therapies and teases his “favorite” nurse, which is the nurse he’s talking to at the moment. The physical therapist tells the SLP that Mr. Jones is having trouble sequencing the steps for safely using his walker.
While directly treating a hip fracture isn’t in the scope of practice for an SLP, helping Mr. Jones succeed in his therapy is within the scope of practice for the SLP. As Heather Jeng wrote last week, walking requires thinking. There is a relationship between cognitive impairment and fall risk. SLPs can help.
Writing Sequencing Goals for Assistive Devices
You know those goal banks and goal writing tools in many electronic health record programs? More often than not, I don’t use them when writing goals for patients with moderate (or more) cognitive impairment. Those goal writing tools aren’t aren’t specific enough, when I’m writing habilitative rather than rehabilitative goals.
If I were to use the goal bank and develop a goal like “Patient will sequence 3-5 step tasks of moderate difficulty with 80% acc given min visual and mod verbal cues”. That goal seems SMART (Specific, Measurable, Attainable, Realistic, Timely), but if the person I’m working with isn’t able to generalize, then the goal isn’t specific enough. I might say the goal is met, because Mr. Jones is able to sequence the steps for using his walker safely, but Mr. Jones may not be able to sequence other 3-5 step tasks of moderate difficulty. So I might write this “Patient will communicate 5 steps for safe ambulation with 90% acc given min visual and mod verbal cues”.
Therapy Tasks for Sequencing
For the purposes of this post, I’ll continue to focus on sequencing with a walker. Although, these treatment tasks could be used for a variety of tasks that need to be sequenced.
Reorder the Steps
Many of us have pages of worksheets where patients are supposed to reorder the 4-5 step task by placing 1-5 in the blanks. I usually don’t use these when the primary goal is sequencing of walker and safe ambulation. Correctly sequencing of the steps to make a bed is unlikely to generalize and result in the person being able to correctly recall and use steps to safely operate their walker or other assistive device. (I may use these types of worksheets with patients where I have written rehabilitative goals and expect generalized improvement.)
Instead, I’ll write down the steps for their individualized task sequence. I determine what their individualized sequence is by talking to the PT to find out if their sequence varies from the norm. I’ll even try to observe the patient completing the task with the PT. It’s my goal to reduce the task to as few of steps as possible. I remove any steps that happen naturally. I once worked with a woman who ALWAYS put her hands back before she sat down, so I removed that step from her sequence. She still completed the step, as it was natural for her to do so, but limiting the number of steps reduced cognitive load.
I also make sure that I write down and use steps in my patients’ words. I do whatever I can help people own the task. If they are having to learn new names of things or phrases, then that will increase the cognitive load. I had one patient who referred to locking the brakes as “punching the brakes”. She demonstrated the targeted action with that verbal cue, so we called it punch the brakes.
Once I’ve got the steps, I’ll write them on note cards and have patients rearrange them in the correct order. I may start to putting them all in order except one and have the patient tell me where the one goes in the sequence. Later I’ll have them reorder the steps with all the cards mixed up.
Reordering the steps isn’t usually my go to task, because there isn’t much in the way I can do with visual cues, it’s not as closely connected to actually completing the task as I’d like it to be, and it’s easy for errors to occur.
I love errorless learning for addressing fall risk when someone has cognitive impairment. I use errorless learning when I have a patient teach me a correct transfer sequence. Gradually fading cues may look like this:
- Give patient written instructions for sequencing task. Tell patient to tell me what to do as I complete the sequencing task. I’ll include verbal cues by saying “Okay, number 1 says…” (and have them read it) and so on, while I use visual cues such as jazz hands to bring attention to my hands moving.
- Still with the patient reading the instructions, I’ll have them continue to give me instruction with verbal and visual cues such as “Then I put my hands …” (and have them fill in the blank) as I slowly move my hands to the targeted location.
- Next, still with the instructions, I’ll figure out which steps they are close to mastering and before that step tell the to tell me without looking at the instructions. I’ll continue to use verbal and visual cues.
- Gradually, the need for using the written instructions fades. Then I’ll just use verbal and visual cues.
- Then I’ll slowly fade the verbal and visual cues until I’m just saying “And then…” to cue to the next instruction.
- Then they will no longer need cues to tell me how to complete the task.
Once we’re not using the written instruction sheet, I like to invite the PT (or OT) to co-treat. Co-treating gives us an opportunity to work toward the same outcome (transferring safely with walker) with two different goals (recall of sequence and mobility). When the PT and OT are on board, then there are more people using the same verbal and visual cues to help the person learn the new sequence.
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