Caseone

“Not being able to go home after • Postpoliosyndrome , after polio-infection 1945, weakness left • Mammacarcinoma 1988: mamma-amputation and post- • Medication: carbaspirin calcium, metformin, simvastatin, • Mobility: did walk with rollator outdoors for longer distances • Personal care: independent; shopping with neighbor/children; • Relations/occupancy: divorced in 1988, two children living • Cognition: mild short term memory loss • Hospital admittance 28th november 2009: • Diagnosis/CT: ischemic stroke right hemisphere ACM • Motor recovery starting within days: • Physical therapist: started to walk with rollator with physical Mrs. R, rehabilitation consultation • Visit by consultant rehabiliation specialist on 2nd of • Motor recovery in progress, adequate, orientated in time. place and person, motivated for rehabilitation • Indication for admittance Rehabilitation Center • Goal: return to home, regain premorbid level of disability Mrs. R, admittance to rehab center • Admittance to Rehab Center on december 15, 2009, after intercurrent admittance to nursing home.
• Mobility: mobilized with rollator, under supervision (not safe) • Personal care: dependent, Barthel 9/20 • Communication: dysarthry, poor eyesight • Cognition: still motivated, easy distractable, poor Mrs. R, admittance to rehab center • Difficulties in controlling blood sugar levels • Consultation ophthalmologist: no explanation for poor • Very slow progress mobility and personal care, distraction, • Neuropsychological assessment dd january 30 2010: • Severe dysexecutive problems: attention, planning, structure, • Home only possible with 24 hour supervision.
• Children were of the opinion that patient was unable to live at • Cognitive dysfunction not explained by cortical • With intensive rehab, gain in independence • But not enough to go home (needs constant • Currently no rehab indication anymore, but were to go to? (She is still in the rehab center, no CIZ indication • Treatment by multidisciplinary team (PT, OT, social work, speech therapist, neuro-psychologist), within stroke-team or unit.
• Stroke unit hospital; after discharge to rehab center, nursing • Indications for rehab center: patient benefits from intensive treatment (physically, mentally, cognitively); dedicated expertise (aphasia, cognition);patient is able to go home after 2-3 months • Young patients to rehab center unless… • “Elderly” patients go to nursing home, but… But life isn’t simple anymore…. • Elderly stroke patients do have multimorbidity which hamper disability/participation prognosis based on stroke itself • Sedentary young versus active old: phenotypes of young and old • This puts higher demands on assessment, prognosis, indication, • Transition of patients from home environment to hospital in case of an event: lack of information from GP/family • Multimorbidity of patients: adequate diagnosis and treatment of age related co-morbidity as malnutrition, dehydration, delirium, • System not tailored to the needs of mrs R: no flexibility • How much do we miss, i.e undertreat at the moment? • Continuity in care for elderly patients: transition from home to hospital and vice versa. (case manager?; who • Optimal assessment of physical, mental and cognitive function from early on (cannot be monodisciplinary • Flexible system: tailored care. At some stage rehab center (complex, intensive), at some stage nursing home

Source: http://www.awo-nzh.nl/nieuws/2010/meskers200410.pdf