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 di ff erence 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 of self determination, and “imposed immobility” — all of which combine to produce a common sense of identity” –Woodard, Havercamp, Zwgart & Perkins (2012)

O Blindness and Visual Impairment M Spectrum of Identity E f a s t t y e a n i b d l k e i s n n h o t e i w f d y s D a m s x d . o i r s e a b t l h e a d n . w e Chronic disease with an d evolving mobility impairment. o . Unaware / unacknowledged. Declining mobility.

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 fi eld < 20 degrees • Method of reading? • Orientation and mobility?

Adaptive strategies for reading • Digital Magni fi cation • 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 signi fi er that does the explaining”

US Census De fi nition: Dif fi culty 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 Impairment Disability Functional Limits Decreased Macular Can’t read Can’t read degeneration visual acuity small type Rx on bottle Disability is a complex interaction between the health condition of the individual and the contextual factors of the environment. -WHO Of the 38,000,000 seniors on Medicare… • 12 million (31%) are fully independent (without accommodation, di ffi culty, 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 di ffi culty but not assistance • 7.7 million (20%) received assistance with ≥ one task

Prevalence of Visual Impairment • 7.7 million adults have di ffi culty 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 (Age 25 to 64 years, percent in and out of poverty) In poverty Not in poverty 91.7 89.6 72.2 27.9 10.4 8.3 Severe Not severe No disability Source: U.S. Census Bureau, 1996 Survey of Income and Program Participation: August - November 1997. 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 • Con fi ned 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

Canes Standard cane Offset cane Quad cane

Proper fi tting of canes & walkers • Align with the wrist crease (with arm relaxed at side), wearing typical shoes • Elbow fl exed 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