Disability
- Determine whether a specific decline in functioning (e.g., social, physical, emotional) is a disability for that specific patient.
- Screen elderly patients for disability risks (e.g., falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis.
- In patients with chronic physical problems (e.g., arthritis, multiple sclerosis) or mental problems (e.g., depression), assess for and diagnose disability when it is present.
- In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
- For disabled patients, offer a multi-faceted approach (e.g., orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
- In patients at risk for disability (e.g., those who do manual labour, the elderly, those with mental illness), recommend primary prevention strategies (e.g., exercises, braces, counselling, work modification).
- Do not limit treatment of disabling conditions to a short-term disability leave (i.e., time off is only part of the plan).
See Elderly.
- Impairment: Structural or functional abnormality/loss - eg. disease (eg. spinal cord injury)
- Disability: Activity limitation for individual - eg. job (eg. unable to walk)
- Limitation: Can do but not at usual force, pace, duration
- Restriction: Cannot or should not do (risk to self/others)
- Handicap: Social disadvantage - fulfill "normal" role (eg. being a father)
Screening for Disability Risks
Screening for Disability Risks
- Falls
- Immobilization
- Vision impairment
- Hearing impairment
- Cognitive impairment
- Poor nutrition, weight loss
- Polypharmacy
- Medical comorbidity (arthritis, diabetes, heart disease, obesity)
- Psychiatric comorbidity
- Psychosocial stressors
Assessment of disabled patient
Assessment of disabled patient
- History
- Occupational history
- Pre-injury function
- Job demands
- Insurance plan
- Medication, substance
- Psychosocial factors (stress, dissatisfaction, relationship)
- Physical exam
- Functional assessment of affected region
- Diagnostic tests
- Referrals (Physiotherapy, occupational therapy, psychologist, specialist consultant)
- ADL/IADLs
- Ability to do work-related activities
- Physical (stand, carry, lift, handle)
- Sensory (hearing, vision)
- Psychiatric (judgment, stress)
- May use a validated questionnaire (eg. SF-36, pain questionnaire)
- Physical (stand, carry, lift, handle)
- Risk assessment
- Does this injury pose a risk to patient or others at workplace
- Formal and informal supports, Family support
- Financial
Treatment of Disability
Treatment of Disability
- Education on diagnosis, treatment, and prognosis
- Emphasize that pain is part of healing process, return to work should not be delayed until pain resolved
- Recommendations and duration
- Capabilities, limitations, restrictions (functional and anatomical, eg. cannot lift right arm above shoulder height, cannot drive until impairing medications not required)
- AVOID getting involved in career planning
- "S̶h̶o̶u̶l̶d̶ ̶n̶o̶t̶ ̶w̶o̶r̶k̶ ̶w̶i̶t̶h̶ ̶b̶o̶s̶s̶" → "Conflict with boss is factor in present illness"
- "D̶i̶f̶f̶e̶r̶e̶n̶t̶ ̶j̶o̶b̶ ̶w̶o̶u̶l̶d̶ ̶b̶e̶ ̶b̶e̶t̶t̶e̶r̶" → "Need for rehab"
- AVOID getting involved in career planning
- Limited time off work, modified work, part-time work (schedule modifications, eg. reduced hours)
- Plan return-to-work at first visit
- Early mobilisation, physical activity
- Physiotherapy, occupational therapy
- Orthotics, walking aid
- Specialist, rehabilitative
- Psychological services if
- Minimal functional gains by 8-12w post-injury
- Somatic symptoms with few objective findings
- Poor adherence to prescribed treatment
- Excessive use of medication
- Psychological indicator (mood, anxiety, anger, substance use)
- Social indicator (conflict in workplace, life stresses, history of prolonged disability)
- Capabilities, limitations, restrictions (functional and anatomical, eg. cannot lift right arm above shoulder height, cannot drive until impairing medications not required)
- Community support
- Treatment of medical/psychiatric comorbidities
- Reviewing medication (polypharmacy)
Prevention of Disability
Prevention of Disability
- Increasing physical activity
- Improved diet and nutrition
- Immunization
Falls
Falls
- 1/3 of people over 65yo have a fall per year
DDx
DDx
- Visual impairment
- Peripheral neuropathy
- CVA
- TIA
- Joint instability
- Deconditioning
- Medication
- Environmental or home hazards
- Orthostatic hypotension
Assessment
Assessment
- Falls in past year
- Problems with gait or balance
- Surrounding circumstances
- Associated symptoms
- Medications
- Acute/chronic medical problems
- Mobility level and cognitive and functional level
- Physical examination
- Gait
- Sensory (hearing and vision)
- Orthostatic vital signs
- Neurological and musculoskeletal assessment
- Depression and cognitive impairment screen
- Review footwear and gait aids
Prevention
Prevention
- Screen/treat osteoporosis
- Vitamin D 1000 units per day
- Individualized exercise program (strength, gait, balance)
- Gait aids
- Home safety assessment (lighting, fix floors, anti-slip shoe devices, hip protectors)
- Medication review / Deprescribing medications
- Cardiac pacing where indicated
References:
- Disablity
- AAFP 2015. https://www.aafp.org/afp/2015/0115/p102.html
- AAFP 2014. https://www.aafp.org/afp/2014/0101/p17.html