By Maureen Colket,  MA, CCC-SLP, LSVT LOUD Certified
Speech-Language Pathologist, Pennsylvania SW

We are taught in our respective graduate school programs how to diagnose and treat patients for their rehabilitation needs. There is a linear progression in school studies of learning typical body systems, followed by what happens when diseases and disorders interrupt these systems. Next, we discover how to implement the best treatment approaches and to improve and manage the variety of diagnoses. 

But what happens when you enthusiastically lay out the plan and your patient says, “I’m not doing that?”

While it’s true that most patients are accepting and appreciative of a clinician’s services, there are those who are not so ready. Rather than looking at these patients as those who “refuse,” let’s think of these situations as a challenge to unlock something that is keeping the patient from accepting care.

Psychological Influence

Managing life with a new diagnosis or disability is life-altering in so many ways. Patients handle these changes in different ways and one’s emotional status can wildly fluctuate from one day to the next. During an evaluation, it is important to take into consideration the psychological state of your patient. Depending on your comfort level, you can ask a variety of questions to help determine this:

• How are you managing with the recent changes?
• What is your support system like?
• What do you do to keep busy?

Additionally, there are many depression screening tools that include much more specific questions than, “Have you been feeling down or hopeless lately?” Some of these tools include:

• Whooley Depression Scale
• Geriatric Depression Scale
• Cornell Scale for Depression in Dementia

According to Kitching, “the incidence of depression may be 30% in vascular dementia and in Alzheimer’s disease and over 40% in the dementia associated with Parkinson’s and Huntington’s diseases”.  These numbers are staggering, yet explain why we come across such a large number of struggling patients.

Anxiety, difficulty coping with changes in late life, and changes in the capacity to make legal and medical decisions are additional real difficulties older adults face. Anxiety, for example, has both mental and physical manifestations and can lead to refusal of treatment, lack of focus during therapy sessions, and overall reduced outcomes in the rehabilitation process.

All of these psychological factors can fluctuate from day to day, moment to moment. When you have identified a patient you are treating as someone struggling with any of these or other psychological or psychiatric disorders/diseases, it is helpful to monitor and adjust your approach in therapy to help your patient achieve his or her best outcome!

Change of Scenery

While it would be nice to transport a therapy session to the beach or other picturesque locale, let’s not forget we can modify the “view” from home for our patients. This can be done by tapping into the senses and making modifications:

Visual Modifications

• Relocate! A welcome change can be as simple as relocating a session from a bedroom where the patient spends the majority of the day due to mobility issues or living in a one-bedroom apartment in a senior living center.
• Take advantage of outdoor time whenever possible!
• Work in an area containing family photographs or bring them to the patient’s area if possible. Being surrounded by those you love, even if it’s only a photograph, can be very motivating!
• Change the lighting to suit your patient. Does dim light help or hurt the situation? Would extra brightness help with focus and bring a more cheery personality?

Auditory Modifications:

• Add music! An instant mood booster for many, music can be played in the background (or turned up!) to improve the ambiance. Asking your patient to choose the music they wish to hear is a small, but true, moment of empowerment.
• By contrast, make it quiet. While we are able to ignore distracting sounds in an environment, this might be very challenging for our patients. Any ways that you can reduce distracting noises can be helpful (e.g., turn off television/radio, put away or silence the patient’s cell phone if allowed, ask caregivers to avoid interrupting for the duration of the session).
• Make it soothing! You might consider playing peaceful sounds such as ocean waves for part or all of your session.

When you take the time to make these personal accommodations, it not only helps the patient perform better in the session but also sends a message to the patient that you care about this patient as an individual. This is part of the rapport-building process and allows you to get to know your patient better. 

I will never forget when I learned a patient of mine loved doo-wop music. I immediately plugged “In the Still of the Night” into my search engine, hit play, and his expression went from sullen to delighted in an instant! When we can connect to patients who are somewhat reluctant to participate in therapy, they have a more invested interest that can snowball into self-motivation.

Maximize Carryover

At the end of our time with a patient, the aim is reaching maximum functional potential as well as maintaining that level long after therapy sessions end. It’s worth going the extra mile to implement an effective home exercise program that is specific to each patient. These programs might all look a little different and that is a good thing! Some tips for effective carryover include:

• Be specific about the time needed to complete the HEP so they can plan accordingly
• Provide a suggested schedule to follow for the HEP
• Keep the HEP concise for ease of understanding as well as quick visual access
• Emphasize the importance of the HEP
• Require that the patient and/or caregiver perform the HEP for you prior to discharge
• Make the HEP fun by focusing on highly preferred exercises/tasks. Don’t be afraid to get creative!

Argent et al. note that non-adherence in HEPs in the rehabilitation professions is estimated to be up to 50%. If this number doesn’t get you rethinking your HEP planning process, I’m not sure what will.  You do not want all of your hard work during a plan of care to be lost due to poor carryover of a home exercise program.  

It is important to keep in mind that we are meeting patients, quite possibly, at their lowest point. They are focused on all of the things they used to be able to do and that can make even the smallest tasks so daunting. The rehabilitation process is not expected to be easy. But, with some modifications to make therapy truly personalized, even the most challenging patients can reach goals even they thought were not possible!