66 yo F with Supranuclear palsy (Client: (caregiver is most concerned…
66 yo F with Supranuclear palsy
problems swallowing possible dysphagia impacting independent eating
inability to self feed due to rigid/jerky movements
postural instability leading to difficulty with functional mobility, feeding, and other ADL/IADLs
min. A to dependent in all ADLs and IADLs (feeding, dressing) due to rigidity and postural instability
requires verbal and tactile cues for most tasks due to decreases in cognition
has limited verbal communication limiting social participation
rigid/jerky movements, postural instability and lowered cognition lead to homebound status
Montreal Cognitive assessment (MOCA)
MOCA will give a better understanding of the current level of cognitive impairment to assess how intervention should be completed.
“up to half of patients with PSP exhibit some level of general cognitive impairment in the early stages”(Gerstenecker, et al., 2017)
Modified Barium Swallow Test
“standardized modified barium swallow study (MBSS)... optimize the detection of swallowing impairment” (Hazelwood, Armeson, Hill, Bonilha, & Martin-Harris, 2017).
Her family is concerned with her ability to self feed and believe that she may be suffering from dysphagia
The Modified Barium Swallow Test will confirm or deny the presence of dysphagia which will assist in deciding the safest way to progress in eating-based interventions; whether this is from adapted textures of the food/liquids or adapted utensils and reminders for proper chin placement in swallowing.
Berg Balance Scale
“Balance in rehabilitation is assessed by either using simple single item test e.g. Single leg stance, tandem stance or a more reliable and widely used Berg Balance Scale” (Gaikwad & Writer, 2012)
Berg Balance Test addresses postural instability and her decreased functional mobility.
Some major motor signs of supranuclear palsy are postural instability and falls (Surova, et al, 2015). The Berg Balance scale will assess her risk of falling
Progressive Supranuclear Palsy Rating Scale (PSP-RS)
The Progressive Supranuclear Palsy Rating Scale (PSP-RS) is a 28 question questionnaire with 6 categories comprised of: daily activities (by history), behavior, bulbar, ocular motor, limb motor and gait/midline (Golbe, L., 2007).
This will give a more client-centered idea of occupations valuable to the client as well as her current level of disability.
Parkinson’s Disease Questionnaire-39 (PDQ39 Scale)
Parkinson’s Disease Questionnaire-39 is a 39 question self-report questionnaire that addresses mobility, ADLS, emotional well-being, stigma, social support, cognition, communication, and bodily discomfort. All aspects are used to measure quality of life (Shirley Ryan Ability Lab, 2018).
Clinical Observation/ Interview
Informal evaluation used to gain further information not gathered by formal assessments, subjective to therapist's judgment.
Treatment of PSP is based off of symptoms ”(Intiso, Bartolo, Santamato, & Di Rienzo, 2018).
introduce the effortful swallow- [prevent and modify]
client is at risk of aspiration pneumonia due to possible dysphagia
The effortful swallow technique helps to clear the food by elevating the hyoid bone and thus reduces residue (Collins, 2018).
proper positioning for feeding-modify and prevent
Proper positioning should be upright and slightly reclined to have gravity aid in swallowing (Benavente, 2018).
Evidence shows that tucking the chin also aids in the swallow technique (Ra, Hyun, Ko, & Less, 2014).
Supranuclear palsy affects posture which could limit postural stability during mealtime.
Aspiration pneumonia is the number one killer of those with PSP, a common concern of those with PSP is their limited postural stability that can affect the individual's ability to self feed and can lead to aspiration pneumonia in the long run (Tiley, 2016). Research shows that balance training helps in preventing aspiration in postural instability related cases.
implement assistive technology- modify, establish, and restore
Assistive technology can be used for memory, motor, and communication deficits. Communication modifications would include communication boards, talk-to-text, and physical signing (Madara Marasinghe, 2016).
plate guards and adapted utensils, such as weighted handles and angled utensils, would be appropriate to compensate for rigidity and jerky movements
Research shows that the implementation of assistive technology in the older populations aids in reducing caregiver burden as long as the caregiver understands how the technology works (Madara Marasinghe, 2016).
Button hooks, dressing sticks, and sock-aids would be appropriate to improve performance in dressing ADLs.
Strategy Training would include the introduction of internal rehearsal and external memory trainers to improve function in daily routine (Radomski & Giles, 2014). Modify
Errorless learning is a proven technique that would include the introduction of hand-over-hand and the eventual weaning of hand-over-hand to prevent errors in feeding and improve learning (Radomski & Giles, 2014). Estalish/Restore
Task-environment modification simplifies the environment and reduces choices within the environment for a higher success rate in occupations (Radomski & Giles, 2014). Modify
Outcomes and Goals
prevention/enahancement(AOTA,2014): Self-feeding and reduced caregiver strain
In 6 weeks, client will self-feed Mod I using weighted handles, angled utensils, and plate guards;with the effortful swallowing technique and proper positioning.
Improvement(AOTA,2014):: Independence in assistive technology use
In 6 weeks, client will demonstrate understanding of assistive technologies by dressing by donning shirt with a button hook.independently
Improvement (AOTA,2014): Improved social participation to communicate needs
In 6 weeks, client will Mod I communicate need to use restroom with communication board and no verbal prompting 3/5 opportunities a day.
Quality of life (AOTA,2014) Improved cognitive performance
In 6 weeks, client will perform morning routine minA with the use of memory journal and <3 verbal cues from caregiver.
Modification of task demands to make completion of tasks independently possible and to allow for aging in place to be possible
Modify environment to increase independence in ADLs and IADLs reduced by rigid and jerky movements and postural instability.
Restore balance and proprioceptive awareness to improve performance in functional tasks.
Restore relationships by working on improving communications.
Prevention of caregiver strain or future hospitalization from disease complications by providing caregiver education
Prevent complications from dysphagia by teaching proper techniques in swallowing during mealtime
Enhance and maintain postural stability and muscle strength
Compensate for limitations
The environment, task, and client factors will each play a role in our clients ability to participate in valued occupations.
To allow for improved participation, the environment or task demands would need to be altered or the client factors restored
caregiver is most concerned about her inability to feed herself
66 yo with supranuclear palsy
rapid decline within last year
rigid jerky movements
requires verbal/tactile cues and at least min assist for all occupations
signs of dysphagia/ no longer eating on her own
can respond to yes/no questions with a head shake
her family wants to keep her at home for as long as possible and to ease caregiver burden
Signs/Symptoms, Prevalence, Incidence of supranuclear palsy
“Reported as 6-7 cases per 100,000 persons”(Kent, A., 2013).
“Peak onset reported at age 63 years, no cases reported before age 40 (DynaMed Plus, 2017).
Cognitive Symptoms (Surova, et al., 2015)
Presents similar to dementia
Motor Symptoms (Surova, et al., 2015)
PSP is a type of atypical Parkinsonism syndrome. The most common phenotype is Richardson’s variant, “characterized by early gait instability, falls, supranuclear gaze palsy, axial rigidity, dysarthria, dysphagia, and progressive dementia” (Intiso, Bartolo, Santamato, & Di Rienzo, 2018 p1)
“ the average life expectancy after diagnosis is about 5 to 10 years, although survival as long as l6 years has been documented” (Steffen, T., Boeve, B., Peterson, C., Dvorak, L., Kantarci, K., 2013, pg. 290).